THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


ORTHOPEDIC    SURGERY 


AND 


OTHER    MEDICAL   PAPERS 


BY 

HENRY  JACOB   BIGELOW 

A.M.,  M.D.,  LL.D. 

MEMBER    OP"   THE   MASSACHUSETTS   MEDICAL    SOCIETY  ;     EMERITUS   PRO- 
KESSOK    OF     SURGERY     IN     HARVARD    UNIVERSITY  ;     SURGEON     OF 
THE     MASSACHUSETTS     GENERAL     HOSPITAL;     MEMBER     OF 
THE    AMERICAN    ACADEMY    OF    ARTS   AND   SCIENCES; 
MEMBER   OF   THE   BOSTON    SOCIETY  FOR   MEDI- 
CAL   IMPROVEMENT;     MEMBER    OF    THE 
BOSTON       SOCIETY      OF      NATURAL 
HISTORY  ; 
FOREIGN    HONORARY    MEMBER  OF   THE   CLINICAL   SOCIETY   OF    LONDON,' 
MEMBKE    COHRESPONDANT    ETRANGER    DE     LA     SOCIi5ti5    DE    CHI- 
RURGIE    DE    PARIS;    MEMBRE    HONORAIRE    DE    LA     SOCi:fiT6 
ANATOMIQUE    DE    PARIS  ;     MEMBRE    CORRESPONDANT 
DE  LA  SOCIET]fi  BIOLOGIQUE  DE  PARIS;    SOCIUS 
EXTRANEUS     SOCIETATIS     MEDIC^E    NOR- 

VEGic.E ;    i;tc.,  ETC. 


PV<9i 


i 


BOSTON 
LITTLE,  BROWN,  AND   COMPANY 

1900 


731 


Univkrsity  Press: 
John  Wilson  and  Son,  Cambkidge,  U.  S.  A. 


Biumedical 
LibraiT 

HDD 


"  I  ^HE  miscellaneous  papers  reproduced  in  this  volume, 
-*•  most  of  them  relating  to  Surgery,  include  the  more 
important  of  Dr.  Bigelow's  contributions  to  medical  jour- 
nals. His  Boylston  Prize  dissertation  on  Orthopedic  Surgery 
is  reprinted  —  as  indeed  are  some  of  the  other  articles  — 
chiefly  for  its  interest  as  matter  of  surgical  history. 

Boston,  1894. 


593275 


.  >-v!L 


CONTENTS. 


ORTHOPEDIC    SURGERY. 

Page 

Introduction 3 

Strabismus 4 

Anatomical  Considerations 4 

Movements  of  the  Eye 7 

Functions  of  Muscles =  7 

Causes  of  Strabismus 9 

Muscular  Paralysis 11 

Double  Strabismus 13 

Anatomical  Peculiarities 14 

Age 15 

Operations 15 

Appreciation  of  the  Different  Methods 22 

Exuberant  Granulations 28 

Subsequent  Treatment  of  the  Eye 28 

Subsequent  Treatment  of  the  Deformity 29 

Bad  Results  of  the  Operation 32 

Cicatrization  of  Parts , 33 

Dimness  of  Vision 33 

Myopy 33 

Diplopy o 35 

Kopiopy .     ,     .     .  35 

Nystagmus 35 

Statistics » 36 

Stammering       37 

General  Remarks  . 38 

Analysis  of  Articulate  Sounds » .  39 

Operation  of  Dieffenbach 42 

French  Operation 44 

Accidents  after  the  Operation 47 


vi  CONTENTS. 

Stammering,  —  continued.  Page 

Appreciation  of  the  Different  Methods 49 

Statistics 52 

Tenotomy 53 

Subcutaneous  Cicatrization  of  Divided  Tendons 55 

General  Characters  of  Deformity 57 

Contraction  and  Retraction 57 

Pathological  Transformations 58 

Instruments  and  Manual  of  the  Operation 59 

Hemorrhage 60 

Mechanical  Treatment 61 

Club-Foot      ...          62 

Causes 62 

Retraction 64 

Varieties 64 

!N'omenclature 65 

Equinus 66 

Varus 67 

Valgus 70 

Talus 71 

Treatment  without  Section  of  Tendons 71 

Contraction  and  Retraction 73 

The  Section  of  Tendons 74 

Treatment  of  Talus 75 

Redivision  of  Tendons 79 

Mechanical  Treatment 79 

Machines 81 

Treatment  of  Equinus , 82 

Treatment  of  Varas    .     • 83 

Treatment  of  Valgus 84 

General  Remarks 85 

Torticollis 86 

Causes 86 

Retraction 87 

Symptoms 88 

Stern  o-cleido-mastoid  Muscle 88 

Vertebral  Column        89 

Treatment  without  Section        89 

Age , 90 

Section  of  the  Sterno-cleido-mastoid  Muscle 90 

Section  of  other  Muscles       , 94 

Mechanical  Treatment 94 


CONTENTS.  yii 

Page 

False  Anchylosis  of  the  Knee  Joint      .     , 97 

Causes 97 

Retraction 97 

Pathological    Alterations   of    the    Tissues,   and    their   Conse- 
quences       98 

Diagnosis  of  the  Different  Organic  Lesions .  100 

Treatment 102 

Results 102 

Medical  Treatment 105 

Surgical  Treatment 106 

Treatment  without  Tenotomy 106 

The  Section  of  Tendons ,     .     .     .  107 

Mechanical  Treatment  of  Chronic  False  Anchylosis   ....  110 

Sudden  Extension 110 

Slowly  Progressive  Extension 112 

Restoration  of  Mobility 113 

Mechanical  Treatment,  with  Tenotomy  during  Inflammation  .  114 

Rickety  Knees 115 

Medical  Treatment 116 

Surgical  Treatment 116 

Permanent  Flexion  of  the  Hip  Joint     ........  118 

Operation 118 

Anchylosis 119 

Lateral  Curvature  of  the  Spine 120 

Causes 122 

Causes  of  the  Congenital  Variety     . 123 

Muscular  Retraction 124 

Vertebrae 125 

Thorax 125 

Causes  of  the  Non-Congenital  Variety 126 

Curvature  and  Torsion 127 

Gibbosity 128 

Curves.  —  Their  Position  and  Mechanism      .     . 128 

Twelfth  Dorsal  Vertebra 129 

Curves  of  Compensation 129 

Treatment 131 

Gymnastic  Exercises , 132 

Surgical  Treatment        133 

Operation 133 

Mechanical  Treatment 134 

Portable  Apparatus 134 


viii  CONTENTS. 

Lateral  Curvature  of  the  Spine,  —  continued.  Page 

Parallel  Extension 135 

Sigmoid  Extension 136 

Contraction  of  the  Hand  and  Eingers 138 

Causes 138 

Operation.  —  Its  Results 140 

Propriety  of  Section 140 

Mechanical  Treatment 141 

Congenital  Dislocations 142 

Causes 142 

Locality  and  Progress 142 

Condition  of  the  Muscles  and  Soft  Parts        143 

Fibrous  and  Fatty  Transformations,  etc 143 

Alterations  of  Articulations 144 

Indications  of  Reducibility 145 

Alterations  of  Parts  in  the  Xeighborhood  of  Luxation     .     .     .  146 

Indications  for  Reduction 147 

Means  of  Preparing  for,  Effecting,  and  Consolidating  Reduction  147 

Recent  and  Chronic  Dislocations 148 

Section  of  Muscles  in  Locked  Jaw 149 

Subcutaneous  Section  of  the  Orbicular  Muscles      .     .     .  151 

Appendix. 

Casting  in  Plaster 152 

Description  of  Plates 156 


MEDICAL   PAPERS. 

Dr.  Bowditch's  "Young  Stethoscopist" 161 

New  Physical  Sign 168 

Case  of  Injury  of  Head 173 

Employment  of  a  Xew  Agent  in  the  Treatment  of  Stric- 
tures of  the  Urethra 189 

Notes  from  Clinical  Lectures  on  Surgery    ......  200 

Stellate  Crack  of  the  Radius  at  the  Wrist 240 

Leucocyth^mia 241 

Surgical  Cases  and  Comments 2.50 


CONTENTS.  ix 

Page 
Ununited  Fracture  successfully  treated;  with  Remarks 

ON  the  Operation 259 

Periosteal  Reproduction  of  Bone 289 

Fractures  and  Dislocations  of  the  Elbow  Joint  ....  294 

Cleft  Palate 301 

Turbinated  Corpora  Cavernosa 310 

New   Methods   in   the   Treatment   of    Exstrophy   of  the 

Bladder  and  of  Erectile  Tumors 317 

The  Modern  Art  of  Promoting  the  Repair  of  Tissue. 

Lectui-e  1 326 

Lecture  II. 340 

Radical  Cure,  without  Operation,  of  a  large   Umbilical 

Hernia 351 

Fees  in  Hospitals ,..,...  354 

An  Old  Portrait  of  a  Surgeon 361 


ORTHOPEDIC  SURGERY. 


PREFACE. 

THE  works  I  have  consulted  in  writing  this  dissertation 
are  chiefly  those  of  Guerin,  Bonnet,  Velpeau,  Phillips, 
Duval,  and  Little ;  especially  the  brochures  of  M.  Guerin,  who 
has  been  for  some  time  the  leading  French  orthopedist. 

The  writings  of  M.  Guerin  may  be  fairly  criticised,  both 
for  the  wordiness  and  obscurity  of  their  style  and  for  their 
unnecessary  bulk ;  but  it  does  not  appear  that  we  have  any 
right  to  question  the  accuracy  of  their  statements.  On  the 
contrary,  we  may  infer  from  the  late  report  of  the  committee 
appointed  by  the  Academy  of  Medicine  to  investigate  this 
point,  that  there  is  no  ground  f^r  supposing  the  evidence  in 
any  way  warped  or  misrepresented. 

It  is  possible  that  M.  Guerin  has  availed  himself  of  the 
suggestions  of  previous  writers ;  that,  in  common  with  other 
specialists,  he  has  overestimated  the  importance  and  the 
efficacy  of  his  art;  that  he  has  been  indiscreet  in  its  appli- 
cation; and  that  "the  division  of  forty-two  tendons,  muscles, 
etc.  upon  the  same  subject"  was  an  audacious  undertaking 
rather  than  "  a  remarkable  achievement."  But  it  should  not 
be  forgotten  that  the  scientific  acquirements  and  practical 
skill  of  this  orthopedist  are  undisputed ;  that  he  is  the  author 
of  valuable  discoveries,  confirmed  as  such  by  the  Academy 
of  Medicine,  and  that,  much  as  he  may  be  indebted  to  pre- 
vious writers,  the  account  has  at  least  been  squared  by  the 
compensating  drafts  of  those  who  have  followed  him. 


2  ORTHOPEDIC  SURGERY. 

The  article  upon  Strabismus,  the  first  of  this  dissertation,  is 
somewhat  disproportioned  in  length  to  the  subsequent  sec- 
tions. The  materials  were  originally  collected  without  the 
intention  of  incorporating  them  into  this  work.  In  allowing 
them  to  retain  their  present  extent,  I  was  decided  mainly  by 
the  fact  that  no  complete  treatise  upon  this  subject  had  ap- 
peared upon  this  side  of  the  water.  The  same  is  true  of  the 
section  on  Stammering,  the  operation  for  which  is  now  a 
matter  of  history,  —  a  curious  instance  of  the  indiscreet  zeal 
of  some  of  the  noted  Continental  surgeons. 


ORTHOPEDIC  SURGERY.! 

INTRODUCTORY. 

It  is  obviously  difficult  to  procure  evidence  upon  which 
a  direct  answer  to  the  question  proposed  by  the  Committee 
should  be  based.  The  subject  is  comparatively  new,  and 
demands  further  investigation.  Among  its  different  depart- 
ments, it  is  easy  to  show  why  the  present  operation  for 
stammering  should  be  proscribed ;  but  it  is  not  easy  to 
indicate  the  cases  which  require  a  section  of  the  muscles  of 
the  back,  or  of  the  tendons  of  the  hands  and  fingers.  These 
questions  can  be  decided  only  by  a  careful  analysis  of  a  large 
number  of  cases,  with  reference  to  the  pathological  conditions 
of  the  subject,  and  the  results  of  different  methods  of  treat- 
ment. They  have  not  been  settled  by  those  most  conver- 
sant with  this  branch  of  surgery,  and  demand  opportunities 
which  are  probably  afforded  only  by  the  larger  European 
institutions. 

It  is  believed  that  the  general  intention  of  the  Committee 
will  be  fulfilled  by  an  attempt  to  cover  the  ground  now 
occupied  by  Orthopedic  Surgery. 

^  A  Dissertation  which  obtained  the  Boylston  Prize  for  1844',  on  the 
following  question  :  "  In  what  cases,  and  to  what  extent,  is  the  division 
of  muscles,  tendons,  or  other  parts,  proper  for  the  relief  of  deformity  or 
lameness  ?  " 


ORTHOPEDIC   SURGERY. 


STRABISMUS. 

But  few  years  have  elapsed  since  the  operation  for  Stra- 
bismus was  announced,  under  circumstances  of  considerable 
interest.  It  proposed  the  relief  of  an  obvious  and  frequent 
deformity,  with  little  pain  or  hazard  to  the  patient,  and  at 
the  same  time  promised  to  the  surgeon  the  notoriety  which 
attends  a  new  and  successful  operation.  Thus  recommended, 
it  rapidly  gained  ground,  and  was  performed  many  hundred 
times  in  Europe  and  in  this  country,  not  only  by  competent 
surgeons,  but  by  operators  who  either  were  not  qualified  to 
investigate  the  lesion  from  a  scientific  point  of  view,  or  whose 
interest  it  was  to  furnish  incorrect  or  partial  statements  of 
their  results. 

Of  the  memoirs  upon  this  subject,  many  offer  a  limited 
series  of  observations,  inadequate  for  purposes  of  induction ; 
others  are  manifestly  inexact ;  and  a  still  greater  number  are 
controversial  essays,  adapted  to  advance  a  particular  method, 
or  its  advocate.  The  following  details  have  been  drawn  from 
'the  few  more  authentic  papers  which  have  recently  appeared. 

ANATOMICAL   CONSIDERATIONS. 

The  ball  of  the  eye  offers  little  worthy  to  be  noted  in  con- 
nection with  this  operation.  The  Sclerotic  is  a  dense,  resist- 
ing coat,  which  may  be  freely  denuded  with  probe  pointed 
instruments  without  risk  of  perforation  or  other  mechanical 
injury ;  neither  does  it  readily  become  inflamed. 

Vessels.  —  A  case  of  alarming  hemorrhage  from  the  opera- 
tion has  been  published  in  the  English  journals,  and  seems 
to  have  been  the  result  of  a  decided  hemorrhagic  diathesis  in 
the  patient  a  child  of  eleven  years  of  age.     The  hemorrhage 


STRABISMUS.  5 

was  arrested  after  the  transfusion  of  several  ounces  of  blood 
from  the  arm  of  a  healthy  adult.  In  a  normal  condition  of 
the  circulating  system,  the  arteries  of  the  orbit  are  not  of  a 
size  to  occasion  danger  or  inconvenience  from  hemoi-rhage, 
while  the  veins  in  the  region  of  the  ethmoid  bone  are  easily 
avoided. 

Nerves.  —  It  seems  superfluous  to  suggest  that  the  optic 
nerve,  inserted  somewhat  nearer  the  inner  than  the  outer 
angle  of  the  eye,  may  be  wounded  by  a  deep  and  careless  dis- 
section upon  the  nasal  aspect  of  the  globe.  An  instance  of 
its  actual  division  in  this  way  has  nevertheless  been  reported. 
The  internal,  superior,  and  inferior  recti  muscles,  and  the 
inferior  oblique,  are  supplied  by  different  branches  of  the 
motor  communis  or  third  pair ;  while  the  superior  oblique 
and  external  rectus  muscle,  each  appropriating  a  separate 
nerve,  are  supplied  by  the  fourth  and  sixth  pairs  respectively. 
No  ill  effect  results  from  the  section  of  the  branches  of  these 
nerves  at  the  point  where  the  muscle  is  usually  divided. 

Muscles.  —  The  four  recti  and  two  oblique  muscles  of  the 
globe  are  the  chief  agents  in  the  production  of  strabismus. 
The  vivid  red  of  the  muscular  fibre  can,  in  most  cases,  be 
detected  at  the  bottom  of  the  incision,  while  the  fan-like  ex- 
pansion of  their  tendinous  insertions  is  often  invisible  among 
the  surrounding  tissues.  The  anterior  tendinous  fibres  of  the 
four  recti  muscles  are  inserted  at  the  distance  of  two  or  three 
lines  from  the  cornea,  while  other  fibres  attach  themselves  to 
the  sclerotic,  a  line  or  two  behind ;  so  that  the  whole  some- 
what resembles  in  form  the  adhering  tail  of  a  leech,  to  which 
it  has  been  aptly  compared. 

The  superior  oblique  muscle  springs  from  the  fibrous  sheath 
(jf  the  optic  nerve,  traverses  the  pulley  at  the  upper  and  inter- 
nal angle  of  the  orbit,  and,  turning  backward  and  outward, 
joins  the  sclerotic  beneath  the  superior  rectus  muscle  and  a 
little  behind  its  insertion. 


6  ORTHOPEDIC  SURGERY. 

The  inferior  oblique  leaves  the  superior  maxillary  bone  in 
the  neighborhood  of  the  lachrymal  sac,  and,  retreating  a  little, 
winds  outward  round  the  globe  of  the  eye,  to  be  inserted  upon 
its  uppgr  and  external  surface. 

Aponeuroses.  —  Much  attention  has  been  directed  of  late 
years  to  this  part  of  the  anatomy  of  the  eye,  especially  by 
Guerin,  Velpeau,  and  Bonnet  (de  Lyons).  Their  researches 
have  demonstrated  two  principal  fibrous  expansions. 

The  first,  which  lines  the  periosteum  of  the  orbit,  retreats 
upon  the  optic  nerve  behind,  and  being  continued  forward 
upon  the  eyelids  to  their  free  edges,  envelops  in  this  manner 
the  whole  contents  of  the  bony  orbit. 

The  second  is  in  contact  with  the  sclerotic,  which  it  covers 
and  protects  as  it  were  from  the  surrounding  adipose  matter. 
In  front,  it  is  reflected  upon  the  internal  surface  of  the  con- 
junctiva, which  it  lines  up  to  its  insertion  at  the  edge  of  the 
lids,  where  it  unites  with  the  aponeurosis  of  the  bony  orbit. 
Behind,  it  is  prolonged  upon  the  optic  nerve,  where  it  again 
joins  the  orbitar  aponeurosis,  with  which  it  forms  a  shut  sac, 
from  which  the  globe  of  the  eye  is  excluded,  much  as  the 
intestine  is  excluded  from  the  cavity  of  the  peritoneum. 
This  sac  is  traversed  by  the  muscles,  each  of  which,  as  it 
enters  the  cavity,  borrows  from  it  a  fibrous  envelope,  which 
is  reinserted  at  its  point  of  exit.  A  tube  is  thus  formed, 
which  gives  passage  to  the  muscle  without  affecting  the 
integrity  of  the  sac. 

It  will  be  remembered  that  these  aponeuroses  are  chiefly 
noted  for  the  role  which  different  writers  have  assigned  them 
in  ocular  deformity,  and  the  impediment  they  are  supposed  to 
offer  to  the  various  steps  of  the  operation.  They  have  also  a 
certain  influence  in  the  normal  movements  of  the  eye,  to  be 
hereafter  examined. 


STRABISMUS. 


MOVEMENTS  OF  THE  EYE. 


Muscles.  —  The  action  of  the  recti  muscles  upon  the  ocular 
globe  is  easily  understood ;  and  I  am  not  aware  of  any  dilfer- 
ence  of  opinion  upon  this  point.  If  a  single  muscle  acts,  the 
pupil  turns  towards  it,  upon  a  vertical  or  horizontal  line.  If 
two  juxtaposed  muscles  contract,  the  pupil  moves  obliquely  in 
the  diagonal  of  the  forces  thus  applied.  Less  is  known  of  the 
action  of  the  oblique  muscles,  and,  while  eminent  writers  have 
cited  a  variety  of  evidence  in  support  of  their  different  theo- 
ries upon  this  point,  the  contradictory  character  of  their  opin- 
ions leads  us  to  doubt  their  accuracy.  That  certain  forms  of 
strabismus  are  said  to  require  a  division  of  these  muscles  is 
a  sufficient  apology  for  a  somewhat  detailed  examination  of 
the  movements  attributed  to  them. 

The  superior  oblique  draws  the  point  of  its  sclerotic  inser- 
tion towards  the  cartilaginous  pulley,  while  the  action  of  the 
inferior  oblique  is  direct. 

Cruveilhier  ascribes  to  the  superior  oblique  a  simple  action 
of  rotation  of  the  ocular  globe  upon  its  antero-posterior  diame- 
ter, the  eye  being  at  the  same  time  slightly  carried  forward  in 
the  orbit.  To  the  inferior  oblique  he  attributes  a  similar  ro- 
tation in  an  opposite  direction. 

Velpeau  supposes  that  the  superior  oblique  carries  the  eye 
inward  and  downward ;  while  at  other  times  it  rather  aids  the 
external  rectus  and  inferior  oblique  in  external  strabismus. 

Charles  Bell  has  termed  the  superior  oblique  a  respiratory 
muscle,  from  its  supposed  influence  in  raising  the  eye  in  the 
expression  of  certain  emotions  ;  as  in  sighing.  In  experiments 
upon  the  dead  subject,  he  found  the  eye  turned  downward  and 
outward  by  traction  upon  this  muscle.  As  it  antagonizes  the 
inferior  oblique  muscle,  he  suggests  that  its  involuntary  relax- 
ation in  certain  expressions  gives  an  opportunity  for  the  action 
of  the  latter  muscle,  which  then  rolls  the  pupil  upward. 


8  ORTHOPEDIC  SURGERY. 

A  later  and  more  plausible  theory  of  Guerin^  and  Skolaski  ^ 
is  supported  by  a  number  of  pathological  observations,  and  can 
easily  be  tested. 

Examine  the  eyes  of  a  person  at  a  convenient  distance,  and 
draw  imaginary  horizontal  lines  through  spots  upon  the  con- 
junctiva. Let  the  head  now  be  laterally  inclined  toward  the 
shoulder,  and  it  will  be  seen  that  the  imaginary  lines  continue 
horizontal,  and  parallel  with  the  floor  or  ceiling  of  the  apart- 
ment, although  their  position  in  relation  to  the  lids  be  changed ; 
in  other  words,  the  eye  tends,  by  a  rotation  upon  its  antero- 
posterior axis,  to  retain  its  relative  vertical  position.  What- 
ever be  the  utility  of  such  an  involuntary  movement,  it  must 
be  allowed  that  it  belongs  to  the  oblique  muscles,  as  supposed 
by  these  physiologists,  although  it  attributes  to  the  inferior 
oblique  branch  of  the  third  pair  of  nerves  the  power  of  pro- 
ducing involuntary  action. 

Aponeuroses.  —  The  aponeuroses  are  said  to  possess  a  cer- 
tain influence  upon  the  movements  of  the  eye.  In  the  lateral 
movements  of  the  ball,  the  angles  of  the  lids  enlarge  at  the 
approach  of  the  pupil ;  and  certain  writers  have  supposed  this 
action  to  be  due  to  a  simple  traction  of  that  portion  of  the 
aponeurosis  of  the  globe  which  is  prolonged  to  the  free  edge 
of  the  lids.  A  permanent  displacement  of  the  eyeball  would 
then  occasion  permanent  traction  of  the  lids. 

But  this  explanation  is  open  to  objection.  "Were  the  har- 
mony of  action  between  the  lids  and  the  globe  due  to  a  purely 
mechanical  influence  of  the  fibrous  tissues,  it  would  follow, 
when  the  pupil  is  buried  beneath  the  roof  of  the  orbit,  that 
both  lids  should  be  equally  elevated  by  their  respective  apo- 
neuroses. The  pupil  rolls  thus  upward  in  the  involuntary 
motions  described  by  Charles  Bell,  a  fact  verified  by  placing 
the  finger  upon  the  lids  while  they  are  forcibly  shut.     It  is 

i  Communication  k  I'lnstitut,  Aout,  1840. 

*  Memoire  adressee  h  la  Societe  de  Medecine  de  Gand,  1840. 


STRABISMUS.  9 

then  observed  that,  while  the  pupil  rises  involuntarily,  the 
upper  eyelid  falls,  —  an  antagonizing  action  directly  opposed 
to  the  upward  traction  of  the  ball  upon  the  upper  lid.  The 
lower  lid  seems  to  be  more  directly  attached  to  the  globe.  It 
follows  the  elevated  pupil,  and  never  antagonizes  the  superior 
lid  so  well  as  when  the  eye  is  rolled  up  beneath  the  orbit. 

The  importance  of  these  aponeuroses  in  their  healthy  con- 
dition seems  to  have  been  exaggerated.  It  is,  however,  easy 
to  suppose  that  bands  of  condensed  cellular  tissue  might 
attach  themselves  to  various  parts  of  the  orbit  and  globe,  and 
tend  to  impede  the  free  motions  of  the  eye,  especially  were 
the  globe  retained,  by  muscular  contraction  or  otherwise,  in  a 
given  position  for  a  length  of  time. 

CAUSES   OP   STRABISMUS. 

Strabismus  is  characterized  by  a  want  of  harmony  in  the 
action  of  the  eyes.  The  internal  recti  muscles  alone  possess 
the  power  of  producing  a  voluntary  strabismus,  or,  in  other 
words,  an  exaggeration  of  the  convergent  action  which  directs 
both  eyes  towards  a  single  object. 

The  duration  of  strabismus  varies  with  its  exciting  causes. 

One  variety  of  the  deformity  depends  upon  a  transient 
spasmodic  action  of  the  muscles.  It  is  observed  in  many 
individuals  while  talking,  and  is  sometimes  of  but  momen- 
tary duration.  Different  exciting  causes  of  this  variety  have 
been  noticed  :  a  moment  of  anger,  an  elevated  temperature,  a 
current  of  air  upon  the  forehead,  or  any  cause  which  acts 
upon  the  nervous  system.  Temporary  strabismus  has  been 
known  to  precede  the  catamenial  discharge,  and  has  been 
observed  in  infants  immediately  before  the  development  of 
dentition. 

Another  variety  accompanies  apoplexy,  or  other  grave 
lesions  of  the  brain ;  while  a  third  class  result  from  tumors 
in  the  soft  or  bony  tissues  of  the  orbit ;  in  which  cases  the 


10  ORTHOPEDIC  SURGERY. 

deformity  is  symptomatic,  and  directs  attention  to  the  more 
serious  affection. 

There  are,  however,  certain  forms  of  strabismus  less  imme- 
diately connected  with  important  organic  lesion,  which  depend 
upon  the  physiological  conditions  of  the  surrounding  tissues. 
In  these  cases  the  affection  may  originate  in  the  muscles,  or 
the  nerves  which  supply  them ;  or  result  from  a  derangement 
in  that  part  of  the  machinery  of  the  eye  which  is  directly 
concerned  in  the  sense  of  vision. 

Muscular  Contraction.  —  While  the  operation  was  yet  new 
in  England,  Sir  Astley  Cooper  remarked  to  the  writer  of  this 
paper  that  he  believed  it  would  not  generally  succeed.  Cor- 
rection of  the  deformity  of  a  limb  was  mainly  due  to  treat- 
ment after  operation,  but  the  nature  of  the  eye  forbade  the 
application  of  an  efficient  orthopedic  apparatus.  Strabismus 
has  been  elsewhere  termed  club-foot  of  the  eye ;  but  the  con- 
dition of  the  parts  is  not  such  as  to  warrant  this  comparison. 
If  a  club-foot  be  examined,  the  retraction  is  found  to  be  firm 
and  permanent.  The  foot  yields  very  little  to  the  application 
of  a  considerable  force.  But  if  in  a  common  case  of  ocular 
deformity  the  sound  eye  be  closed,  it  will  be  found  at  the  end 
of  a  certain  time  that  the  pupil  of  the  affected  eye  emerges 
from  the  angle  of  the  lids  and  advances  to  take  its  place  in 
the  centre  of  the  orbit,  while  the  sound  eye  is  in  its  turn 
everted.  In  the  former  case  the  muscle  has  lost  its  power 
of  elongation;  it  often  undergoes  a  transformation  which 
assimilates  its  substance  to  that  of  fibrous  tissue.  In  the 
eye,  on  the  other  hand,  the  muscle  retains  its  anatomical 
structure,  and  such  a  transformation  is  very  rare.  In  four 
hundred  and  twenty-two  cases  operated  upon  by  Phillips, 
fibrous  transformation  occurred  three  times ;  while  in  more 
than  five  hundred  patients  only  two  cases  of  fatty  transfor- 
mation were  observed. 

What  then  is  the  condition  of  the  muscle  in  the  majority 


STRABISMUS.  11 

of  cases  ?  Accumulated  testimony  seems  to  warrant  the 
assertion,  that  the  muscle  is  in  a  condition  of  permanent 
but  active  contraction ;  an  explanation  readily  accepted, 
when  it  is  remembered  that  a  great  number  of  cases  are 
sudden  in  their  access,  and  date  from  the  convulsions  of 
infancy. 

Optic  Strabismus  is  a  term  applied  by  M.  Guerin  to  the 
deviation  which  sometimes  follows  distortion  of  the  pupil,  or 
opacities  upon  the  cornea  in  the  axis  of  vision.  As  the  rays 
of  light  are  thus  hindered  from  reaching  the  retina  in  a  direct 
line,  the  eye  deviates  from  a  central  position  in  such  a  way 
as  to  present  either  a  transparent  portion  of  the  cornea,  or 
the  pupillary  aperture,  directly  to  the  object.  Although  these 
cases  are  not  uncommon,  every  surgeon  has  observed  central 
opacities  of  the  cornea  without  ocular  deviation.  M.  Guerin 
supposes  that  this  sort  of  distortion  forbids  operation.  On  the 
other  hand,  M.  Velpeau  affirms  that  the  deformity  presents 
no  greater  tendency  to  reappear  in  these  cases  than  in  others, 
and  in  balancing  the  amount  of  vision  obtained  by  the  de- 
formity against  the  personal  attractions  lost  by  it,  he  con- 
siderately submits  the  question  to  the  vanity  of  the  patient. 
Surgeons  having  thus  acquired  the  power  of  correcting  stra- 
bismus at  the  expense  of  the  sight,  it  obviously  remained  for 
some  ingenious  oculist  to  reverse  the  process  and  restore  the 
vision  by  producing  a  squint.  This  has  been  done  by  M. 
Cunier,  He  proposes,^  in  cases  of  central  opacity  of  the 
cornea,  to  divide  one  or  more  muscles  of  the  eye,  so  as  to 
determine  a  strabismus  which  shall  put  the  pupil  in  relation 
with  that  portion  of  the  cornea  which  remains  transparent, 
and  thus  permit  the  light  to  arrive  at  the  bottom  of  the  eye. 

Strahistnns  from  Muscular  Paralysis.  —  The  affection  which 
gives  rise  to  this  form  of  strabismus  has  received  much  atten- 
tion of  late  years  from  ophthalmic  surgeons,  and  especially 

^  Lettre  k  I'Academie  des  Sciences,  1841. 


12  ORTHOPEDIC  SURGERY. 

from  M.  Siclicl.  Its  effect  is  analogous  to  the  distortion 
observed  iii  the  extremities  when  the  paralysis  of  certain 
muscles  is  followed  by  the  unopposed  retraction  of  their  an- 
tao-onists.  It  occurs  in  certain  cases  of  a  paralytic  affection 
of  one  or  several  of  the  muscular  fasciculi.  If  the  external 
rectus  be  alone  involved,  the  eye  deviates  to  the  side  of  the 
nose.  If  the  internal  rectus  be  affected,  external  strabismus 
is  the  result;  and  the  eye  turns  up  or  down,  as  the  inferior 
or  superior  straight  muscles  cease  to  act  upon  it. 

An  affection  of  the  third  pair  of  nerves  sometimes  occasions 
paralysis  of  the  three  muscles  which  it  supplies,  and  the  ex- 
ternal rectus  alone  retains  its  power. 

Distortion  of  this  sort  is  distinguished  from  common 
strabismus  by  the  inability  of  a  patient  to  direct  his  eye 
towards  the  affected  side  when  the  other  eye  is  closed.  The 
deviation  is  sometimes  slight,  and  the  eye  merely  refuses  to 
follow  its  companion  in  certain  directions,  while  otherwise 
it  moves  freely.  It  is  less  easy  to  distinguish  a  paralysis  of 
several  muscles  from  that  form  of  strabismus  which  results 
from  adhesion  of  the  surrounding  tissues  and  immobility  of 
the  eyeball.  A  degree  of  motion,  however,  exists  in  most 
cases,  and  were  there  none  the  former  might  be  distinguished 
by  its  capability  of  passive  or  forced  motion,  which  the  fixed 
immobility  of  the  other  forbids. 

These  varieties  of  strabismus  have  been  subjected  to  opera- 
tion. It  is,  however,  evident  that  remedies  should  be  directed 
to  the  original  lesion,  so  long  as  they  promise  a  chance  of  re- 
lief. If  the  case  assume  a  chronic  form,  beyond  aid  from 
remedial  agents,  an  operation  may  be  resorted  to,  with  a 
view  of  restoring  the  eye  to  the  centre  of  the  lids.  It  is 
sometimes  accompanied  with  advantage  to  the  sight,  but  is 
more  frequently  an  operation  de  complaisance. 

Paralysis  of  the  Oblique  Muscles  is  more  difficult  of  diag- 
nosis.    Two   cases,  probably  of   this   affection,  reported   by 


STRABISMUS.  13 

M.  Skolaski,'  seem  to  confirm  the  supposition  already  referred 
to,  that  these  muscles  exercise  an  action  of  rotation  upon  the 
eyeball.  In  both  these  interesting  cases,  the  eye  refused  to 
imitate  the  rotatory  motion  of  its  fellow  when  the  head  was 
turned  towards  the  shoulder,  and  in  this  position  diplopy 
ensued.  The  images  were  superposed,  and  mutually  receded 
in  a  vertical  direction  as  the  head  was  inclined,  that  of  the 
stationary  eye  being  always  below. 

The  various  duties  assigned  by  different  observers  to  these 
muscles  have  been  enumerated  at  some  length  in  another 
part  of  this  paper;  and  it  has  been  seen  that  the  most 
contradictory  opinions  have  been  entertained  of  their  real 
purpose.  It  cannot,  therefore,  be  shown  what  variety  of 
distortion  would  result  from  their  permanent  contraction. 
In  fact,  they  have  often  been  divided  for  strabismus ;  but  the 
results  of  the  few  trustworthy  observations  upon  this  point 
are  so  widely  opposed  that  their  section  must  be  regarded,  at 
present,  as  purely  experimental. 

Strabismus  from  Amaurosis.  —  Functional  or  other  lesion 
of  the  optic  nerve  has  been  considered  both  as  a  cause  and 
an  effect  of  ocular  distortion.  It  is  undoubtedly  true  that 
amaurotic  eyes  are  not  exempt  from  the  various  distortions 
which  affect  these  organs.  If  amaurosis  is  a  cause  of  stra- 
bismus, restored  vision  will  probably  rectify  the  deviation. 
The  effect  of  the  operation  upon  amaurosis  will  be  again 
adverted  to. 

DOUBLE   STRABISMUS. 

In  most  cases  of  simple  strabismus  if  the  patient  be  directed 
to  regard  a  distant  object  he  does  so  with  the  sound  eye,  while 
the  affected  eye  squints.  The  sight  of  the  deviating  organ  is 
often  imperfect.     It  is  not  uncommon  to  meet  with  patients 

1  Longet,  Anatomie  et  Physiologie  du  Systeme  Nerveux,  Paris,  1842, 
torn.  ii.  p.  396.     (See  ante,  p.  8.) 


14  ORTHOPEDIC   SURGERY. 

who  have  acquired  a  habit  of  using  the  sound  eye  for  more 
remote  objects,  while  tlie  squinting  and  often  near-sighted  eye 
is  reserved  for  reading  or  viewing  objects  close  at  hand, 
and  a  singular  effect  is  produced  by  their  ability  to  advance 
either  pupil  at  will.  But  it  sometimes  happens  that  both 
eyes  present  a  slight  deviation.  In  such  cases  the  operation 
should  be  confined  to  that  which  presents  the  greatest  distor- 
tion. A  month  should  be  allowed  to  elapse  before  operating 
upon  the  second,  as  during  that  time,  in  a  majority  of  cases, 
the  movements  of  the  two  eyes  become  parallel. 

Velpeau  concedes  that  it  is  difficult  to  distinguish  cases  of 
really  double  strabismus  from  those  which  are  so  only  in  ap- 
pearance and  which  demand  but  a  single  operation  to  correct 
an  apparent  double  deformity.  M.  Phillips  operates  upon 
both  organs  only  when  the  deviation  in  the  two  eyes  is  uni- 
form, and  then  only  at  an  interval  of  a  month  or  more. 

ANATOMICAL   PECULIARITIES. 

Adhesions  of  the  Globe  give  rise  to  permanent  strabismus, 
distinguished  by  its  incapability  of  passive  or  forced  motion. 
These  cases  result  from  wounds  and  deep-seated  inflammation 
of  the  orbit.  Yelpeau  alludes  to  cases  not  referable  to  such 
conditions,  in  which  the  muscle  adhered  to  the  sclerotic  as 
far  as  the  posterior  part  of  the  eye.  The  operation  requires 
extended  dissection,  and  is  liable  to  be  followed  by  readhe- 
sion.  Successful  results  have,  nevertheless,  been  reported  by 
Velpeau  and  others. 

Triple  Insertion.  —  The  internal  and  superior  recti  muscles 
are,  in  rare  instances,  divided  into  two  or  three  fasciculi  at 
their  then  fanlike  insertions,  either  of  which  may  aid  in  pro- 
ducing a  deviation. 

Fibrous  and  Fatty  Transformations  of  the  muscles  are  rare, 
and  have  been  elsewhere  mentioned. 


STRABISMUS.  15 


AGE. 


Neither  infancy  nor  old  age  has  been  exempted  from  this 
oft  repeated  operation.  In  young  infants  the  deformity  some- 
times disappears  spontaneously,  while  old  people  rarely  care 
to  be  relieved  of  it.  After  the  age  of  three  or  four  years 
the  chances  of  success  are  greater  in  proportion  to  the  youth 
of  the  patient.  M.  Velpeau  asserts  that  the  tissues  require 
a  more  extended  division  in  old  people. 

OPERATION. 

Though  definitely  indicated  by  Stromeyer,  in  1838,  and  per- 
formed upon  the  dead  body  by  that  surgeon,  the  operation  for 
strabismus  was  first  applied  to  the  living  subject,  in  modern 
times,  by  Dieffenbach,  on  the  26th  of  October,  1839. 

It  is  probable  that  a  similar  operation  was  practised  many 
years  ago.  The  following  curious  advertisement  of  an  English 
oculist,  named  Taylor,  who  lived  in  the  last  century,  is  to  be 
found  in  the  "  Mercure  de  France,"  Annee  1737,  Juin,  p.  1180  : 
"Doctor  Taylor,  Oculist  of  the  King  of  Great  Britain,  has  re- 
cently arrived  at  the  Hotel  de  Londres,  Rue  Dauphine,  Paris, 
where  he  proposes  to  stay  till  the  beginning  of  July,  after 
which  he  will  leave  for  Spain.  He  begs  us  to  publish  the 
discoveries  he  has  made  to  restore  squinting  eyes  by  a 
rapid  operation,  almost  without  pain,  and  without  fear  of 
any  accident." 

M.  Cunier^  refers  to  a  singular  phrase  in  the  dissertation 
of  Verheyden,  printed  in  1767 :  "  Strabones  permultos  ferro 
sanatos  apud  Anglicos  vidi." 

Whatever  be  inferred  from  these  passages,  the  operation 
was  unknown  to  surgeons  at  large  until  of  late  years. 

M.  Carron  du  Villards  pretends  to  have  thought  of  it  in 
1838. 

1  Annales  d'Oculistique,  !*■■  Vol.  Supplementaire,  Bruxelles,  1842,  p.  258. 


16  ORTHOPEDIC  SURGERY. 

Dr.  Ingalls,  of  Boston,  Massachusetts,  is  said  to  have  sug- 
gested it  as  far  back  as  1812-13. ^ 

Pauli,  a  surgeon  of  Landau,  in  1839,  was  only  prevented 
from  attempting  it  by  the  indocility  of  his  patient.  But  the 
first  authentic  operations  upon  either  the  dead  or  the  living 
subject  belong  to  the  surgeons  of  Hannover  and  Berlin. 

A  few  months  sufficed  to  introduce  this  surgical  novelty 
into  England  and  France.  I  was  present  in  September,  1840, 
at  some  of  the  earliest  experiments  made  in  London.  The 
simplicity  and  safety  of  the  operation  soon  became  known, 
and  the  new  ground  was  at  once  occupied  by  a  host  of  ex- 
plorers striving  to  identify  themselves  with  its  success.  All 
were  armed  with  peculiar  and  indispensable  instruments, 
with  curious  hooks  and  complicated  scissors,  and  with  knives 
studiously  fashioned  to  differ  from  one  another.  The  method 
continually  varied ;  and  there  were  few  surgeons  who  had 
not  an  operation  of  their  own,  distinguished  by  their  name. 

The  general  principles  of  these  different  methods  are  the 
same;  and  I  propose  to  examine  them  under  the  three  fol- 
lowing heads : — 

Those  which  resemble  the  operation  of  Stromeyer  and 
Dieffenbach,  in  which  the  conjunctiva  is  first  divided. 

Those  in  which  all  the  tissues  are  divided  at  once,  as  in 
the  method  of  Yelpeau. 

The  subconjunctival  method  of  Guerin. 

In  each  method  the  aim  of  the  operation  is  the  division  of 
the  muscle,  and  it  is  of  little  real  importance  whether  it  be 
effected  in  one  way  or  another.  But  there  is  hardly  a  sur- 
geon or  an  oculist  who  has  not  suggested  some  superfluous 
modification  or  complication  of  this  simple  manoeuvre ;  and 
within  a  week  I  have  observed  in  one  of  the  journals  the 
reinvention  of  an  instrument  contrived  some  two  years  since. 
In  the  words  of  Mr.  Liston,  "  All  this  is  for  the  use  of  those 

1  Medical  Examiner,  February,  1841. 


STRABISMUS.  17 

gentlemen  practising  surgery  who  are  deficient  in  dexterity, 
and  for  the  benefit  of  the  cutlers."  A  somewhat  tedious  ex- 
amination of  tlie  more  important  methods,  if  it  serve  no  other 
purpose,  may  tend  to  show  that  there  is  httle  new  to  be  con- 
trived either  in  the  instruments  or  the  manual  of  this  frequent 
operation. 

For  greater  convenience  the  operation  is,  in  general,  de- 
scribed with  reference  to  convergent  strabismus  of  the  right 
eye. 

Operation  of  Stromeyer.  —  The  sound  eye  being  covered,  the 
patient  is  directed  to  turn  the  affected  eye  outward.  A  small 
double  hook  is  implanted  in  the  conjunctiva  at  the  internal 
part  of  the  globe,  and  confided  to  an  aid.  The  fold  of  con- 
junctiva is  then  raised  with  forceps  near  this  point,  and 
divided  vertically  with  a  cataract  knife ;  after  which  the  aid 
draws  the  eye  outward,  while  the  surgeon  passes  a  small 
curved  director  underneath  the  muscle,  and  divides  it  with 
the  knife  or  curved  scissors. 

It  should  be  remembered  that,  in  operating  upon  the  dead 
subject,  Stromeyer  was  not  compelled  to  confine  the  lids. 

DieffeyihacKs  Method  is  similar,  but  characterized  by  a 
greater  complication  of  instruments,  and  requiring  more  as- 
sistance. The  instruments  are  the  elevator  of  Pellier  for  the 
upper,  and  a  double  blunt  hook  with  a  long  slender  handle 
for  the  lower  lid ;  two  slender  hooks  to  pierce  and  raise  the 
fold  of  conjunctiva ;  scissors  curved  on  the  flat,  to  divide  the 
conjunctiva  and  the  muscle  ;  a  blunt  hook  to  insinuate  be- 
neath the  muscle  ;  and  finally,  in  refractory  patients,  a  double 
short-pronged  hook,  to  pierce  the  sclerotic  and  confine  the  eye. 
Two  assistants  in  general  suffice.  The  patient  is  seated 
opposite  the  light,  the  head  resting  upon  the  chest  of  an  as- 
sistant. The  surgeon  sits  in  front  of  the  patient,  without  ex- 
cluding the  light,  and,  passing  the  elevator  beneath  the  upper 
lid,  transfers  it  to  his  assistant.     The  double  hook  depresses 

2 


18  ORTHOPEDIC   SURGERY. 

the  lower  lid,  and  is  held  by  the  second  assistant,  who  kneels. 
The  fold  of  conjunctiva  is  now  suspended  between  the  two 
small  hooks ;  the  first,  at  the  inner  angle,  being  confided 
to  the  first  assistant,  while  the  second,  near  the  cornea,  is 
retained  by  the  operator  in  his  left  hand.  The  fold  is  snipped 
with  curved  scissors,  and  the  muscle  exposed  by  dissection. 
The  surgeon  then  abandons  the  scissors,  introduces  the  blunt 
hook  beneath  the  muscle,  and,  as  a  final  step,  divides  it  with 
the  scissors. 

In  some  of  his  earlier  operations,  Dieffenbach  excised  a 
portion  of  the  tendinous  extremity  of  the  divided  muscle, 
but  subsequently  renounced  this  process. 

Tlie  Operation  of  Phillijys,  a  pupil  of  Dieffenbach,  is  nearly 
identical  with  the  preceding. 

Gruthrie's  Method.  —  In  the  operations  which  I  saw  per- 
formed by  Mr.  Guthrie  in  September,  1840,  the  manual 
resembled  that  of  Stromeyer.  The  lids  being  controlled  by 
instruments,  or  by  the  finger  of  the  operator  and  that  of  an 
assistant,  the  sclerotic  was  transfixed  by  a  double  hook,  and 
the  eyeball  everted.  The  conjunctiva  being  then  raised  upon 
a  hook  and  opened,  a  slight  dissection  exposed  the  muscle.  A 
curved  director  was  now  passed  beneath  the  muscle,  and  served 
to  guide  a  short  pointed  and  curved  bistoury  in  dividing  it. 

Methods  of  Ferral  and  Lucas.  —  These  differ  little  from 
that  of  Dieffenbach.  In  that  of  Ferral,  the  forceps  are  sub- 
stituted for  one  of  the  conjunctiva  hooks,  and  angular  for 
curved  scissors. 

Liston's  Method.  —  With  a  view  of  dispensing  with  one 
assistant,  this  surgeon  proposes  to  fix  the  eye  and  raise  the 
conjunctival  fold  by  a  pair  of  spring  toothed  forceps,  which, 
once  attached  to  the  conjunctiva  near  the  inner  angle,  are  left 
to  themselves  and  by  their  weight  confine  the  lower  lid. 

The  Methods  of  Roux  and  of  Sedillot  resemble  that  of 
Guthrie  in  the  use  of  the  curved  director.     To  fix  the  globe, 


STRABISMUS.  19 

M.  Sedillot  employs  a  hook  with  three  branches,  each  fur- 
nished with  a  small  sphere  like  a  shot  at  the  distance  of  a  line 
from  its  point,  to  prevent  it  from  penetrating  the  sclerotic  too 
deeply. 

Baudens's  Method. — The  lids  being  fixed  as  in  Dieffenbach's 
operation,  the  surgeon  transfixes  with  a  strong  single  hook 
both  the  conjunctiva  and  the  muscular  attachment.  The  eye 
is  then  drawn  outward,  and  the  muscle  rises  in  a  plait  or 
fold.  Under  this  he  inserts  M.  Baudens's  knife,  and  divides 
the  mucous  coat  together  with  part  of  the  muscle.  The  re- 
mainder of  the  muscle  is  raised  with  a  blunt  hook,  edged  upon 
its  lesser  curve,  which  thus  severs  its  fibres.  M.  Baudens  re- 
moves the  tendinous  insertion,  and  also  trims  the  conjunctival 
edges,  with  a  view  to  relieve  the  wound  of  filaments  which 
might  impede  its  union. 

The  knife  of  M.  Baudens  (Fig.  4)  is  about  an  inch  in  length  <• 
and  a  quarter  of  an  inch  wide  at  the  base,  and  pointed.  It  is 
curved  on  the  edge  to  about  a  quarter  of  a  circle.  It  is  also 
slightly  curved  upon  the  flat,  and  the  point  is  thus  directed 
away  from  the  globe  of  the  eye,  while  the  wedge  shape  of  the 
blade  enables  it  to  cut  its  way  out  in  traversing  its  length. 
It  is  evident  that  a  different  curve  is  required  for  each  eye. 

Method  of  Amussat.  —  This  differs  little  from  those  already 
cited,  except  in  the  blunt  hook  inserted  beneath  the  muscle. 
M.  Amussat  has  contrived  an  instrument  consisting  of  two 
hooks  lying  side  by  side,  and  so  adapted  to  each  other  as 
to  resemble  a  single  one.  These  hooks,  introduced  between 
the  muscle  and  the  eyeball,  are  then  opened,  and  the  mus- 
cular fibres  divided  between  them.  M.  Phillips  asserts  that 
this  instrument  was  previously  invented  and  rejected  by 
Dieffenbach. 

Finally,  M.  Gairal  has  proposed  a  hook  armed  with  a  button 
and  bent  at  right  angles ;  the  distance  from  the  elbow  of  the 
hook  to  the  button  beina:  four  lines.     This  serves  to  designate 


20  ORTHOPEDIC  SURGERY. 

the  position  of  the  tendon  in  measuring  the  distance  between 
its  insertion  and  the  edge  of  the  cornea.  Introduced  beneath 
the  muscle,  the  arm  of  the  instrument  is  sufficiently  long  to 
embrace  the  fibres  in  all  their  width. 

OPERATION    IN   WHICH    ALL   THE   TISSUES   ARE   DIVIDED   AT    ONCE. 

First  Method  of  Velpeau.  —  The  lids  being  held  apart  by 
instruments,  a  double  hook  is  plunged  into  the  sclerotic  near 
the  cornea,  and  the  eye  drawn  outward.  A  strong,  single 
hook  is  thrust  under  the  muscle  near  the  angle  and  a  fold 
thus  raised.  With  a  small  curved  knife  the  entire  fold  is 
divided,  consisting  of  the  muscular  fibres,  cellular  tissue,  and 
the  conjunctiva. 

31.  Andrieux  proposes  to  give  the  hook  an  edge  upon  its 
lesser  curve,  which  would  then  cut  its  way  out. 

Second  Method  of  Velpeau.  —  The  lids  are  separated  by  a 
self-adjusting  speculum  termed  a  hlephareirgon  (Fig.  13),  in- 
vented in  England  and  modified  by  M.  Velpeau.  With  a 
strong  pair  of  toothed  forceps,  the  surgeon  seizes  the  inser- 
tion of  the  tendon  and  everts  the  eye.  With  a  similar  pair, 
which  he  afterwards  abandons  to  an  aid,  he  grasps  the  muscle 
and  conjunctiva  at  the  angle.  He  then  divides  the  muscle 
and  surrounding  tissues  near  its  middle  with  a  pair  of  curved 
or  straight  scissors,  the  blunt  points  of  which  are  repeatedly 
passed  backward  and  forward  upon  the  sclerotic,  to  plough 
up  any  accidental  undivided  fibres.  A  last  stroke  of  the 
scissors  excises  the  tendinous  insertion,  and  its  conjunctival 
covering,  still  retained  by  the  forceps. 

This  operation,  which  I  have  repeatedly  seen  performed  by 
M.  Yelpeau,  involves  a  free  division  of  the  tissues  surround- 
ing the  retracted  fibres. 

The  teeth  of  forceps  intended  to  grasp  the  tissues  exterior 
to  the  sclerotic  should  be  slightly  recurved,  that  their  con- 
vexity may  repel  this  membrane  when  pressed   against   it, 


STRABISMUS.  21 

while  their  approaching  extremities  pierce  the  tissues  in 
immediate  contact  with  them. 

M.  Velpeau  sometimes  uses  but  one  pair  of  forceps,  and 
the  operation  then  resembles  that  proposed  by  M.  Daviers 
(d'Angers). 

A  sponge  is  often  required  during  the  operation,  and  a  pair 
of  slide  forceps  has  been  contrived  to  hold  it,  attached  to 
the  handle  either  of  the  knife  or  the  scissors  (Fig.  4). 

SUBCONJUNCTIVAL   METHOD. 

Applying  to  the  eye  the  principles  of  subcutaneous  opera- 
tions, M.  Guerin  has  adopted  a  process  which,  though  some- 
what complicated,  deserves  attention. 

The  instruments  in  this  operation  are  peculiar.  A  spear 
resembling  a  saddler's  awl,  whose  greatest  width  is  rather 
less  than  a  quarter  of  an  inch,  an  inch  in  length,  and  slightly 
•curved  upon  the  flat  that  it  may  follow  the  ocular  sphere, 
serves  to  pierce  the  mucous  envelope. 

The  shaft  of  the  knife  employed  is  first  bent  to  a  right 
angle,  and  then  rebent  to  its  original  direction  at  the  interval 
of  about  an  inch  (Figs.  6,  7).  Two  elbows  are  thus  formed,  to 
one  of  which  is  attached  a  strong  handle,  while  the  blade  at 
the  other  is  an  inch  in  length  and  slightly  convex  on  the 
edge.  They  allow  the  handle  of  the  instrument  to  lie  flat 
upon  the  cheek  or  forehead  of  the  patient,  while  the  blade  is 
l)eneath  the  muscle  to  be  divided,  and  perpendicular  to  its 
fibres.  In  other  words,  the  bend  in  the  shank  of  the  knife 
adapts  it  to  the  depression  of  the  eye  beneath  the  orbitar 
ridge. 

The  manual  is  as  follows.  The  patient  lies  upon  a  table, 
the  head  supported  by  a  pillow,  while  the  lids  are  confined 
by  any  of  the  common  means.  A  double  hook  is  plunged  into 
the  sclerotic  near  the  cornea,  and  when  the  eye  is  everted 
abandoned  to  an  aid.     A  fold  of  conjunctiva  is  now  raised 


22  ORTHOPEDIC  SURGERY. 

near  the  insertion  of  the  tendon  with  a  hook,  which  the 
operator  holds  in  his  left  hand,  while  with  his  right  the 
spear  is  carefully  passed  to  the  depth  of  half  an  inch  along 
the  inner  surface  of  the  muscle,  and  then  withdrawn.  The 
operator  then  directs  the  blunted  point  of  the  knife  towards 
the  occiput,  enters  it  at  the  aperture,  and  engages  it  beneath 
the  muscle.  As  a  second  step,  he  depresses  the  handle  upon 
the  cheek,  so  that  the  blade  lies  across  and  beneath  the 
muscle,  while  the  shank  of  the  knife,  between  its  elbows,  is 
engaged  in  the  small  conjunctival  aperture.  By  a  third 
manoeuvre,  he  turns  towards  the  muscle  the  edge,  which 
previously  looked  towards  the  occiput.  Extracting  the  now 
useless  hook  from  the  conjunctiva  and  taking  in  his  left 
hand  the  sclerotic  hook  from  the  aid  who  has  held  it,  he 
gently  draws  the  eye  outward,  while  with  his  right  he  severs 
the  muscle  by  a  sawing  motion  of  the  knife.  Its  division 
is  attended  with  a  slight  noise,  audible  at  some  distance. 
The  surface  of  the  eye  is  then  explored,  by  ploughing  its 
surface,  as  it  were,  with  the  blunted  point  of  the  knife,  and 
thus  any  remaining  fibres  are  divided.  The  instrument  is 
withdrawn  with  a  movement  the  reverse  of  that  by  which  it 
entered. 

Such  is  the  operation  in  which  I  have  often  assisted  M. 
Guerin.  With  a  little  manual  dexterity  it  is  quite  sim- 
ple, and  seldom  occupies  more  than  half  a  minute  in  its 
execution. 

APPRECIATION   OF   THE   DIFFERENT  METHODS. 

Before  examining  the  details  of  the  operation,  it  will  be 
well  to  determine  as  nearly  as  possible  the  conditions  most 
important  to  its  success.  At  Paris  the  early  operations  of 
MM.  B,oux,  Sedillot,  and  others  were  eminently  unsuccess- 
ful. Of  ten  cases  reported  by  M.  Velpeau,  three  only  were 
radically   cured   of  the   deformity.     When    the  method  of 


STRABISMUS.  23 

Dieffenbach  was  better  understood,  results  were  more  favor- 
able. Phillips,  a  pupil  of  this  surgeon,  operating  in  the 
presence  of  Amussat,  Baudens,  and  Lucien  Boyer,  obtained 
from  them  the  avowal  "that  they  at  last  understood  why 
until  then  they  had  only  met  with  failure ;  and  they,  with 
reason,  referred  the  constant  success  of  this  operation  to  M. 
Phillips's  use  of  the  blunt  hook  of  Dieffenbach  in  searching 
for  the  contracted  muscle. " 

It  will  have  been  observed  from  what  has  preceded  that 
the  chief  use  of  the  blunt  hook  {crochet  mousse,  Fig.  5)  is  in 
searching  for  such  undivided  filaments  as  may  have  escaped 
the  first  division  of  the  muscle.  Its  blunt  point  is  repeatedly 
passed  backward  and  forward,  up  and  down,  in  a  direction 
perpendicular  to  that  of  the  muscular  fibres;  and  being 
urged  against  the  sclerotic  it  seldom  fails  to  insinuate  it- 
self beneath  the  tissues  nearest  in  contact  with  this  mem- 
brane, which  are  then  easily  raised  and  divided. 

To  a  similar  cause  M.  Velpeau  attributes  his  want  of  suc- 
cess, as  will  be  inferred  from  his  remarks  upon  the  operation 
of  M.  Phillips:  "Seeing  M.  Phillips  operate  upon  the  dead 
subject,  I  at  once  understood  that,  in  imitating  him,  we 
could  hope  to  succeed  where  we  had  before  completely  failed. 
In  fact,  observing  that  he  divided  the  conjunctiva  and  all  the 
tissues  contained  in  the  orbit,  over  at  least  a  third  of  the 
surface  of  the  globe  of  the  eye,  I  perceived  that  among  my 
patients  numerous  layers  destroyed  by  M.  Phillips  must  have 
remained  in  place.  For  my  part,  I  had  not  dared,  at  first, 
so  largely  to  denude  the  sclerotic,  or  to  perform  a  dissection 
in  the  orbit  at  once  so  extended  and  so  profound.  I  avoided 
this  with  extreme  care,  and  aimed  especially  to  confine  the 
division  of  the  conjunctiva  and  the  other  tissues  to  a  very 
limited  extent.  The  fear  of  seeing  a  phlegmonous  inflam- 
mation establish  itself  in  the  orbit  did  not  permit  me  to 
go   further.      M.    Phillips  having  affirmed  that   the  conse- 


24  ORTHOPEDIC   SURGERY. 

quences  of  such  extensive  denudation,  and  of  a  division  of 
the  tissues  which  had  alarmed  me  upon  the  living  subject, 
were  extremely  simple  and  involved  no  serious  accident,  and 
having  soon  after  demonstrated  the  truth  of  his  assertions 
in  operating  upon  patients,  my  convictions  were  changed, 
and  the  question  soon  assumed  a  new  phase." 

A  complete  division  of  the  parts  is  then  the  great  aim  of 
the  operation ;  and  it  is  safe  to  assert  that,  so  long  as  any 
contracted  filaments  remain  undivided  the  success  of  the 
operation  will  be  compromised.  A  partial  section  may  in 
some  instances  suffice;  but  at  present  it  is  impossible  to  dis- 
tinguish such  cases,  or  to  designate  in  the  orbit  the  particular 
fibres  concerned  in  the  deformity. 

In  dissecting  perpendicularly  down  upon  the  sclerotic  we 
endanger  its  integrity.  It  is  therefore  necessary  to  interpose 
something  between  this  membrane  and  the  parts  immediately 
in  contact  with  it,  by  which  they  may  be  at  once  discovered 
and  commanded.  Now  it  is  of  little  consequence  whether 
this  be  effected  by  any  of  the  numerous  blunt  hooks  of  dif- 
ferent operators,  by  the  probe-pointed  blade  of  curved  or 
straight  scissors,  or  by  the  rounded  tip  of  M.  Guerin's  knife. 
The  type  and  element  of  the  instrument  employed  is  the 
blunted  hook,  crochet  mousse  of  DiefTenbach ;  split  longitu- 
dinally, and  attached  to  the  crossed  legs  of  the  common  for- 
ceps, it  becomes  the  crochet  a  Scartement  of  Dieffenbach  and 
Amussat;  furnished  with  an  edge  upon  its  inner  curvature, 
it  is  the  crochet  histouri  of  Baudens;  armed  with  a  point  and 
curved,  it  is  the  crochet  tranchant  of  M.  Andrieux,  the  myotome 
(I  double  courbure  of  Baudens,  and  the  common  curved  bis- 
toury of  other  surgeons.  It  is  also  recognizable  in  the  blade 
of  common  curved  scissors,  which,  in  the  hands  of  M.  Yel- 
peau,  are  straight;  while  with  M.  Guerin  a  knife  attached 
to  a  crooked  handle  answers  the  purpose. 

This   step   of   the   operation   I   consider   essential.     The 


STRABISMUS.  25 

manual  varies  with  the  taste  and  habits  of  different  sur- 
geons ;  but  in  every  method  there  is  a  blunted  point  thrust 
between  the  sclerotic  and  the  last  undivided  fibres.  These, 
being  once  discovered  and  elevated,  are  easily  cut  if  raised 
upon  the  blunt  hook  by  a  knife  or  scissors,  or  by  the  sharp 
edge  of  the  hook  itself,  if  it  have  one.  They  are  equally 
well  divided  between  the  arms  of  the  crochet  of  Amussat,  by 
the  twin  blades  of  scissors,  and  finally,  in  the  subcutaneous 
operation,  by  the  edge  of  the  tenotome. 

The  othei-  parts  of  the  operation  may  be  considered  in  their 
order.  The  upper  lid  is,  in  general,  better  held  by  the  com- 
mon elevators  than  by  the  finger  of  an  assistant,  though  the 
latter  is  often  sufficient.  As  in  other  operations  upon  the 
eye,  the  finger  should  be  covered  with  cotton  cloth,  which 
absorbs  the  secretions  and  maintains  a  better  hold  upon 
the  lid. 

The  lower  lid  may  be  confined  by  the  forefinger  of  the 
operator's  left  hand,  or  by  a  double  hook  held  by  an  aid. 
The  forceps  of  M.  Liston  attached  to  the  conjunctiva  are 
painful,  and  should  only  be  employed  when  other  assistance 
is  not  at  hand. 

Snowden's  hlephareirgon  appears  to  offer  the  most  effect- 
ual and  simple  means  of  fixing  the  lids.  The  metallic  band 
attached  to  it  by  Charriere  is  unnecessary  and  inconvenient. 
The  pain  it  occasions  is  slight,  and  the  instrument  makers 
are  in  the  habit  of  applying  it  to  their  own  eye  to  show  its 
efficiency.  It  might  be  rendered  still  less  painful  by  a 
thread  confining  the  arms,  so  as  to  prevent  their  diverging 
beyond  a  certain  point. 

In  most  methods  the  globe  is  commanded  by  a  small  double 
hook,  which  penetrates  the  sclerotic.  It  should  be  fixed  by 
a  sudden  stroke,  as  in  entering  a  cataract  needle.  In  case 
of  failure  with  it  the  wounded  eye  should  be  allowed  a 
short  repose,  as  it  often  takes  on  a  convulsive  action  and 


26  ORTHOPEDIC   SURGERY. 

becomes  difficult  to  manage.  This  hook  offers  several  ad- 
vantages. While  it  controls  the  eye  it  enables  the  surgeon 
to  extend  or  relax  the  contracted  tissue  as  he  secures  and 
divides  it.  In  the  method  of  Dieffenbach  the  eye  is  less 
securely  held  by  a  flap  of  conjunctiva. 

The  conjunctiva  may  be  raised  by  hooks  or  toothed  for- 
ceps,—  hooks  being  less  painful,  forceps  more  secure.  If  the 
conjunctiva  be  alone  transfixed  one  or  two  hooks  may  be 
used  at  the  taste  or  discretion  of  the  operator;  but  when  all 
the  tissues  are  to  be  included  in  the  fold  two  forceps  are 
evidently  more  effectual,  though  M,  Velpeau  occasionally 
employs  but  one. 

The  incision  of  the  conjunctiva  when  near  the  cornea  is 
less  liable  to  be  followed  by  gaping  of  the  lids  and  depres- 
sion of  the  caruncula  than  when  near  the  angle  of  the  eye. 
If  prolonged  upward  it  should  terminate  as  near  as  possible 
to  the  lower  edge  of  the  muscle.  The  division  of  the  aponeu- 
roses downward  tends  to  induce  a  fall  of  the  lower  lid,  and 
a  consequent  enlargement  of  the  palpebral  aperture. 

The  length  of  the  incision  varies  in  different  methods. 
While  M.  Phillips  denudes  a  third  or  more  of  the  ocular 
circumference,  M.  Guerin  insists  upon  the  advantage  of  a 
simple  puncture  of  a  size  to  admit  the  instrument.  The  truth 
lies  between  these  extremes,  and  it  may  be  affirmed  that  an 
incision  of  about  half  an  inch  in  length  suffices  in  most 
cases  for  convenience  of  manipulation  and  to  expose  the 
tissues  to  be  divided.  Its  length  necessarily  varies,  and  in 
general  increases  with  the  degree  of  the  deviation. 

The  cellular  tissue  once  divided  and  the  red  substance  of 
the  muscle  brought  into  view,  or  its  position  exposed,  its 
fibres  are  raised  by  an  instrument  passed  beneath  it  in  the 
manner  before  indicated.  Premising  that  the  blunt  hook 
requires  least  dexterity,  we  may  leave  the  instrument  to  be 
employed  to  the  option  of  the  surgeon. 


STRABISMUS.  27 

It  is  during  this  dissection  that  the  sponge  is  required; 
and  it  is  most  convenient  when  attached  to  the  handle  of  the 
cutting  instrument. 

With  the  self-adjusting  speculum,  the  operation  of  M.  Vel- 
peau,  which  embraces  at  once  the  tissue  to  be  divided,  is 
rapid  and  simple.  The  use  of  toothed  forceps  is  perhaps 
more  painful  than  that  of  single  hooks,  but  the  whole  method 
is  more  expeditious.  I  have  repeatedly  seen  children  un- 
dergo the  operation  without  manifesting  pain. 

The  removal  of  the  end  of  the  divided  tendon  is  of 
doubtful  efficacy.  Adopted  and  rejected  by  Dieffenbach,  it 
is  now  practised  by  Velpeau  and  by  Phillips,  but  it  is  not 
essential  to  success.  It  is  affirmed  by  these  operators  that, 
in  precluding  the  possibility  of  union  by  first  intention,  the 
excision  of  the  tendon  reduces  the  chance  of  a  return  of  the 
deformity.  Phillips  asserts  that  it  never  causes  accident,  is 
not  painful,  and  that  it  diminishes  the  quantity  of  exuberant 
granulations. 

The  subconjunctival  method  of  M.  Guerin  has  been  much 
decried.  Its  results,  of  which  I  have  seen  many  examples, 
have  appeared  to  me  quite  as  successful  as  those  of  other 
methods,  although  I  have  no  statistics  upon  this  point.  The 
manual  dexterity  requisite  for  its  performance  has  prevented 
its  general  adoption,  and  has  probably  interfered  with  its 
success  in  other  hands  than  those  of  its  inventor.  Never- 
theless, it  has  often  proved  efficient  among  skilful  operators. 
It  may  be  mentioned  that  Dr.  Cabot  of  Boston  obtained  ex- 
cellent results  from  this  method  in  Yucatan.  The  sclerotic 
surface  should  be  carefully  explored  for  undivided  fibres 
while  the  globe  is  rolled  inward  with  the  sclerotic  hook  and 
the  fibres  thus  relaxed.  When  the  knife  penetrates  beneath 
them,  they  are  to  be  extended  across  its  edge  and  severed. 
This  method  is  often  followed  by  much  ecchymosis,  which  is 
afterwards  absorbed.     On  the  other  hand,  the  open  wound 


28  ORTHOPEDIC   SURGERY. 

of  the  common  method  is  soon  occupied  by  a  bunch  of  fun- 
gous granulations,  fi'om  which  the  narrow  puncture  of 
Ouerin's  operation  is  exempted. 

The  matter  may  be  thus  summed  up :  — 

The  retracted  filaments  are  to  be  completely  divided. 

They  are  best  detected  with  a  blunt  hook,  or  analogous 
instrument,  insinuated  beneath  them. 

The  other  steps  of  the  operation  are  dictated  by  the  incli- 
nation or  habit  of  the  surgeon. 

The  simplest  method  is  that  of  Velpeau. 

SUBSEQUENT   TREATMENT. 

It  will  be  readily  conceived  that  the  treatment  should 
bear  some  proportion  to  the  extent  of  the  incision  and  of  the 
probable  inflammation.  In  many  cases  the  patient  contin- 
ues his  ordinary  avocations  without  inconvenience,  while  in 
some  rare  instances  a  violent  inflammatory  action  ensues. 
In  general,  compresses  wet  with  cool  water  suffice  as  an  im- 
mediate application  to  the  eye.  In  two  days  warm  emollient 
lotions  may  be  substituted,  and  at  the  end  of  three  or  four 
days  a  few  drops  of  some  mild  astringent  collyrium  may  be 
instilled  day  and  night  into  the  angle  of  the  eye.  Attention 
being  paid  to  cleanliness  it  is  rare  that  more  violent  reme- 
dies are  called  for,  and  the  organ,  if  carefully  watched,  may 
be  sometimes  left  to  itself. 

If  the  inflammation  tends  to  gain  the  cornea,  leeches  or  a 
cathartic  are  indicated;  in  short,  ordinary  remedies  are  to 
be  proportioned  to  the  violence  of  the  symptoms.  Sometimes 
a  few  hanging  filaments  of  the  conjunctiva  serve  to  keep  up 
irritation,  and  require  excision. 

Exuberant  Gratudations.  —  A  few  days  after  the  operation, 
if  the  incision  has  been  large,  the  mucous  membrane  presents 
a  number  of  small  elevated  papules,  somewhat  resembling 
bubbles  of  air.     Insensibly  increasing  in  size,  if  kept  wet 


STRABISMUS.  29 

with  cold  compresses,  they  unite,  become  red  and  gorged 
with  blood,  and  tend  to  excite  a  suppurative  action  of  the 
adjacent  surfaces.  If  the  cold  application  be  now  discon- 
tinued the  excrescence  becomes  rounded,  smooth,  shining,  of 
a  pearly  color,  and  finally  pediculated  at  the  base,  when  it 
may  be  snipped  off  without  inconvenience. 

When  not  treated  by  wet  compresses  the  granulations 
sometimes  refuse  to  unite.  Then  they  require  to  be  excised 
separately,  often  with  considerable  hemorrhage,  and  are 
liable  to  be  reproduced. 

Cauterization,  a  more  painful  and  prolonged  procedure,  is 
sometimes  followed  by  cicatrices  with  more  or  less  retrac- 
tion of  the  tissues. 

THE   DEFORMITY   AFTER   OPERATION,   WITH   ITS    SUBSEQUENT 

TREATMENT. 

In  a  large  proportion  of  cases,  when  the  operation  is  well 
performed,  the  deviation  is  at  once  corrected;  and  though 
the  eye  may  be  unable  to  move  in  the  direction  of  the  divided 
muscle,  the  pupil  assumes  a  position  in  the  centre  of  the 
palpebral  aperture.  But  this  is  not  a  constant  nor  always  a 
permanent  result. 

In  certain  cases,  the  strabismus,  though  less  marked,  is 
still  perceptible.  The  sclerotic  has  been  laid  bare  in  the 
region  of  the  retracted  muscle,  but  the  eye  still  deviates  in 
that  direction,  and  further  treatment  is  required  to  correct 
the  deformity.  Various  methods  have  been  devised  for  this 
purpose. 

Division  of  Other  Muscles.  —  It  has  been  shown  that  the 
division  of  the  oblique  muscles  is  uncertain  in  its  results. 

Phillips  divides  the  superior  oblique  when  with  strabismus 
the  cornea  is  convex,  and  the  eye  salient  and  near-sighted. 
M.  Velpeau  has  never  divided  it,  and  states  that  he  knows 
no  authentic  and  conclusive  fact  in  favor  of  its  section. 


30  ORTHOPEDIC  SURGERY. 

Equally  experimental  is  the  division  of  certain  fibres  of  the 
neighboring  recti  muscles.  M.  Velpeau  proposes  to  sever 
the  inner  fibres  of  the  superior  or  inferior  straight  muscles 
in  convergent  strabismus,  and  cites  successful  cases  of  these 
supplementary  sections.  It  should  be  remembered  that, 
while  it  multiplies  chances  of  success,  a  free  dissection  ex- 
poses the  patient  to  a  variety  of  serious  accidents.  It  is  not 
unfrequently  followed  by  exophthalmy,  divergent  strabismus, 
or  fixed  adhesion  of  the  globe,  and  is  for  this  reason  rarely 
justifiable. 

Loop  of  Thread.  —  Dieffenbach  seizes  with  forceps  a  fold  of 
conjunctiva,  with  its  subjacent  cellular  and  fibrous  tissues, 
and  passes  through  it  a  thread,  which  is  subsequently  made 
fast  to  the  nose,  brow,  or  ear  of  the  patient.  The  eye  is  thus 
retained  in  a  normal  position  during  four  or  five  days,  at 
the  end  of  which  time  the  thread  cuts  its  way  out.  This 
method  is,  for  obvious  reasons,  difiicult  of  application. 

Compression.  —  The  convexity  of  the  cornea  affords  a  point 
of  resistance  by  which  the  eyeball  may  be  in  some  sort  fixed. 
The  lids  should  be  closed,  and  a  small,  soft,  globular  com- 
press placed  at  the  angle  fvom  which  the  pupil  is  to  be 
diverged.  It  is  retained  in  place  by  a  bandage  around  the 
head,  which  is  made  to  exert  a  slight  degree  of  compression 
in  the  desired  direction. 

It  should  be  mentioned  that  an  unskilful  application  of  this 
bandage  in  the  service  of  M.  Velpeau  was  followed  by  phleg- 
monous erysipelas  and  destruction  of  the  eye. 

Spectacles.  —  An  advantageous  recourse  frequently  em- 
ployed by  M.  Guerin  consists  of  glasses,  upon  which  paper 
is  pasted  so  as  to  obstruct  vision,  except  at  a  point  distant 
from  the  divided  muscle.  The  pupil  seeks  the  light,  and 
the  eye  is  thus  kept  in  a  favorable  position. 

If  often  suffices  to  cover  the  sound  eye,  and  thus  force  the 
patient  to  exercise  the  other. 


STRABISMUS.  31 

Lastly,  a  slight  deviation  not  unfrequently  disappears 
without  care  on  the  part  of  the  surgeon. 

In  another  class  of  patients,  the  deviation,  corrected  at 
the  time,  tends  to  return  at  an  interval  of  from  one  to  four 
weeks  after  the  operation.  The  same  methods  are  here 
advisable;  especially  that  of  bandaging  the  sound  eye, 
the  use  of  covered  glasses,  or  a  bit  of  pasteboard  bridg- 
ing across  the  orbit,  permitting  vision  only  at  the  point 
required. 

A  /Second  Operation.  —  If  the  wound  has  healed,  it  becomes 
a  question  whether  a  second  operation  is  indicated.  For 
results  of  such  cases  the  reader  is  referred  to  the  numerous 
papers  of  writers  upon  the  subject,  each  of  whom  emulates 
the  other  in  successful  operations  upon  the  uncured  patients 
of  rival  surgeons. 

When  none  of  the  accidents  to  be  hereafter  mentioned  have 
followed  a  first  operation,  it  is  probable  that  no  ill  eifect 
will  result  from  its  repetition,  which  is  better  worthy  of 
trial  when  there  is  the  chance  that  a  previous  operation  was 
incomplete. 

BAD    RESULTS    OF   THE    OPERATION. 

Among  the  bad  effects  of  a  large  division  of  the  tissues  are 
the  following :  — 

Strabismus  in  a  Direction  opposite  to  that  of  the  original  De- 
formity.—  This  demands  the  reverse  of  the  treatment  before 
indicated  for  a  partial  correction  of  the  deviation.  A  com- 
pensating operation  upon  the  contracting  muscle  has  also 
been  resorted  to,  but  this,  while  it  may  relieve  the  deformity, 
tends  to  abridge  the  lateral  motions  of  the  eye. 

Exophthalmy.  —  The  ocular  globe,  deprived  of  a  consid- 
erable portion  of  its  muscular  and  tendinous  attachments, 
advances  in  the  socket,  either  upon  its  antero-posterior  axis 
or  with  a  lateral  inclination.     An  unsightly  deformity  is 


32  ORTHOPEDIC  SURGERY. 

thus  produced  which  is  beyond  the  aid  of  art.  In  certain 
cases,  when  slight,  and  when  it  occurs  immediately  after  the 
operation,  it  subsequently  disappears. 

Depression  of  the  Caruncula  often  accompanies  the  last 
deformity,  but  more  frequently  exists  alone.  It  is  less 
liable  to  occur  when  the  incision  is  made  near  the  cornea 
than  when  at  the  angle.     It  is  irremediable. 

Gaping  of  the  Lids  sometimes  occurs  when  the  dissection 
is  extensive.  Phillips  pretends  to  avoid  this  accident  in 
many  cases  by  prolonging  the  conjunctival  incision  down- 
ward no  farther  than  the  centre  of  the  muscle. 

If  the  falling  of  the  lower  lid  be  considerable  the  deform- 
ity can  only  be  remedied  by  a  corresponding  modification 
of  the  other  eye.  For  this  purpose  the  mucous  coat  is 
seized  by  two  hooks  near  the  insertion  of  the  inferior 
straight  muscle,  and  incised.  The  unsupported  lid  then 
falls,  and  the  similarity  of  the  eyes  renders  the  deformity 
less  obvious. 

Immohility  of  the  Globe.  —  When  a  single  muscle  has  been 
divided  the  movements  of  the  eye,  impeded  at  first,  tend  to 
re-establish  themselves  at  a  subsequent  period.  If  two  mus- 
cles are  divided  it  is  probable  that  the  movements  will  be 
less  completely  restored ;  and  when  the  denudation  is  con- 
siderable the  eye  inclines  to  contract  firm  adhesions  to  the 
surrounding  tissues,  which  terminate  in  an  incapability  of 
motion,  more  or  less  complete,  with  or  without  strabismus. 
It  is  analogous  to  that  produced  by  deep-seated  inflammation, 
which  has  been  before  described. 

Diplopy.  —  Double  vision  not  unfrequently  follows  the 
operation,  and  disappears  in  most  cases  in  three  weeks  or 
a  month,  provided  the  pupils  assume  a  normal  position. 


STKABISMUS.  33 


CICATRIZATION   OF   PARTS   AFTER   THE   OPERATION. 

Until  recently,  little  has  been  established  upon  this  point. 
From  the  comparatively  few  authentic  recorded  observations 
the  following  principles  are  drawn :  — 

If  any  undivided  fibres  retain  the  muscle  in  place  the 
severed  ends  are  apt  to  reunite. 

If  completely  divided  the  posterior  portion  retracts,  and  in 
rare  cases  is  inserted  by  muscular  adhesion  into  the  scle- 
rotic, at  a  point  remote  from  its  original  insertion. 

More  commonly  the  divided  muscle  contracts  tendinous 
adhesions  with  the  sclerotic  near  the  extremity  of  its  trans- 
verse diameter,  and  becomes  united  to  the  anterior  portion 
by  fibrous  prolongations  which  are  firmly  attached  to  the 
ocular  globe. 

DIMNESS   OF   VISION. 

Dimness  of  Vision  is  a  frequent  companion  of  strabismus, 
and  has  been  considered  its  effect. 

It  is  certain  that  in  the  common  form  of  strabismus,  when 
the  disabled  eye  is  brought  into  use,  it  acquires  in  a  large 
majority  of  cases  a  new  and  often  complete  power  of  vision. 
This  improvement  is  sometimes  immediate,  and  sometimes 
gradual. 

The  enfeebled  sensibility  of  the  retina  is  occasionally  so 
considerable  as  to  have  been  mistaken  for  amaurosis.  It  is 
not,  however,  a  contra-indication  of  the  operation,  as  it 
results  in  a  great  number  of  cases  from  the  deformity  itself. 

MTOPY. 

Internal  Movements  of  the  Eye.  —  It  is  evident  that  the 
internal  relations  of  the  different  parts  of  the  eye  must  be 
changed  in  order  to  obtain  successively  a  correct  image  of 
a  near  and  of  a  distant  object.     This  alteration  is  difficult 

3 


34  ORTHOPEDIC  SURGERY. 

to  appreciate,  and  theories  upon  the  subject  have  not  been 
wanting.  The  convexity  of  the  cornea  has  been  supposed 
to  vary,  the  humors  to  change  their  form,  the  crystalline 
its  figure,  and  more  recently  its  position.  .  Perilenticular 
canals  have  been  demonstrated,  ^  which,  with  that  of  Petit, 
serve  as  safety  valves  for  the  temporary  escape  of  the  fluids 
compressed  by  the  movements  of  the  lens.  If  this  action  is 
obscure,  its  immediate  cause  is  much  more  so,  and  is  not 
clearly  shown  to  depend  either  upon  the  oblique  or  the  recti 
muscles  exclusively,  as  different  writers  have  suggested. 

In  the  experiments  of  M.  Bonnet^  upon  the  eye  of  an  albino 
rabbit,  a  distinct  image  of  a  distant  window  was  obtained 
upon  the  retina.  The  eye  was  then  laterally  compressed, 
and  while  the  first  image  was  obscured  that  of  a  neighboring 
lamp  became  distinct.  The  experiment  being  repeated,  it 
was  inferred  that  lateral  compression  of  the  eye  placed  it  in 
conditions  favorable  to  the  perception  of  near  objects;  and 
it  seemed  probable  that  the  position  of  the  oblique  muscles  in 
the  human  eye  best  adapted  them  thus  to  modify  the  organ. 

Myopy  with  Strabismus.  —  If  the  above  be  true,  it  will  be 
readily  conceived  that  an  exaggerated  contraction  of  the 
straight  muscles,  also  compressing  the  ocular  globe  in  their 
position  as  tangents  to  its  circumference,  would  diminish 
its  capacity  for  viewing  distant  objects  and  induce  a  state 
of  myopy  or  near-sightedness.  This  theory  is  confirmed  by 
the  fact,  which  is  I  believe  established,  that  the  near- 
sightedness which  accompanies  strabismus  disappears  in  a 
majority  of  cases  after  the  operation. 

Myopy  without  Strabismus.  —  Attention  has  been  of  late 
directed  to  the  section  of  different  muscles  in  the  common 
form  of  myopy  without  strabismus ;  but  the  results  of  these 
experiments  are  wholly  unsatisfactory.       MM.   Guerin   and 

1  By  Jacobson  of  Copenhagen. 

2  A.  Bonnet,  Traite  des  Sections  Tendineuses  et  Musculaires,  Paris, 
1843,  p.  207. 


STRABISMUS.  35 

Cunier  have  reported  cases  of  relief  after  section  of  the 
external  and  internal  rectus.  M.  Bonnet  claims  similar 
results  from  the  section  of  the  inferior  oblique ;  ^  and  hence 
infers  that  a  section  of  either  of  these  three  muscles  exercises 
a  certain  influence  upon  the  vision.  He  prefers  the  inferior 
oblique,  as  being  easiest  of  access.  In  his  method  it  is 
reached  by  plunging  a  short  pointed  tenotome  through  the 
lower  lid  at  a  point  just  above  the  centre  of  the  edge  of  the 
bony  orbit.  The  knife  is  carried  backward  and  inward, 
nearly  to  the  ethmoid,  the  edge  being  directed  toward  the 
nose.  The  handle  is  then  depressed  toward  the  outer  angle 
of  the  eye,  and  the  blade,  thus  brought  forward,  is  found  to 
have  hooked  up  the  muscle,  which  it  subsequently  divides. 

DIPLOPY. 

It  has  already  been  remarked  that  the  variety  of  double 
vision  which  follows  the  operation  requires  only  time  to 
disappear. 

When  it  exists  before  the  operation,  it  is  generally  relieved 
by  it.  A  dilated  state  of  the  pupil  in  the  affected  eye  seems 
to  contribute  to  it;  and  in  rare  cases  it  has  been  observed  to 
accompany  vision  in  a  single  eye. 

KOPIOPY. 

This  is  a  name  given  by  M.  Petrequin  ^  to  the  sensation  of 
fatigue  experienced  in  the  use  of  the  affected  organ,  either 
before  or  after  operation.  It  seems  to  result  from  the  want 
of  power  in  a  part  rarely  exercised,  and  subsides  as  the  eye 
becomes  habituated  to  its  restored  functions. 

NYSTAGMUS. 

Convulsive  trembling  of  the  eye  is  observed  with  or  with- 
out strabismus.      The  ocular   globe  oscillates   in   different 

1  Op.  cit.,  p.  231.  2  Annales  d'Oculistique,  1841. 


36  ORTHOPEDIC  SURGERY. 

directions,  varying  with  the  muscles  in  fault.  It  turns  in 
certain  cases  upon  its  antero-posterior  axis,  as  if  moved  by 
the  main-spring  of  a  watch  attached  to  this  axis.  This 
motion  corresponds  with  that  which  has  been  referred  to  the 
oblique  muscles. 

When  the  affected  muscles  are  divided,  the  convulsive  ac- 
tion ceases,  but  generally  returns  with  the  reunion  of  the 
parts.  If  we  may  believe  M.  Phillips,  it  is  then  much  less 
marked,  and  diminishes  until  it  finally  disappears.  Of  four 
or  five  patients  operated  upon  by  M.  V^elpeau,  none  were 
radically  cured. 

STATISTICS. 

Subjoined  are  the  results  of  Velpeau  and  Phillips,  as  they 
have  reported  them. 

Velpeau.  —  Three  hundred  cases.  One  half  completely 
successful.  Of  the  other  half,  one  third  presented  a  very 
slight  deviation,  exophthalmy,  depression  of  the  caruncula, 
fixedness  of  the  ball,  or  enlargement  of  the  lids.  In  the 
other  two  thirds  these  accidents  were  very  manifest,  and 
the  patients  retained  a  deformity  as  striking  as  that  which 
existed  before  the  operation. 

Phillips.  —  One  hundred  cases.  Seventy-five  satisfactory 
results,  sixteen  incomplete,  five  not  improved ;  in  five  the  eye 
directed  outwards.  Of  divergent  strabismus,  ten  satisfac- 
tory, five  incomplete,  one  not  improved. 

The  constant  success  reported  by  Dieffenbach  induced  a 
M.  Melchior  to  examine  a  number  of  his  patients.  In  a 
Latin  essay  upon  the  subject,  published  at  Copenhagen,  he 
states  that  of  forty-four  patients  but  ten  were  found  to  be 
entirely  relieved,  and  fifteen  only  partially  so. 

The  results  of  Bonnet,  Chassaigne,  and  Baudens  are  before 
me;  but  the  bearing  of  their  statistics  is  less  obvious,  as 
they  interpret  differently  the  term  "success." 


STAMMERING.  37 


STAMMERING. 


The  operation  for  strabismus  suggested  that  for  stammer- 
ing. When  it  was  ascertained  that  spasmodic  contraction  of 
the  muscles  of  the  eye  was  relieved  by  their  division  it  was 
inferred  that  the  proposition  was  general,  and  a  new  field 
was  sought  for  its  application.  The  characteristics  of  stam- 
mering were  too  obvious  to  escape  notice,  and  hence  the 
operations  for  its  cure. 

Dieffenbach  in  Germany,  and  soon  after  Velpeau  and 
Amussat  in  France,  announced  their  methods. 

The  results  have  not  answered  expectation,  as  might  have 
been  inferred  from  the  complicated  nature  of  the  mechanism 
of  the  vocal  organs.  But  such  was  not  the  belief  of  sur- 
geons, and  the  tongue  was  carved  and  tied,  above  and  below, 
in  any  way  which  seemed  to  offer  a  possibility  of  modifying 
its  previous  physiological  conditions.  The  different  opera- 
tions were  indiscriminately  applied.  It  sufficed  that  a  man 
stammered  and  the  genio-glossi  muscles,  or  the  entire  thick- 
ness of  the  tongue,  were  condemned  to  the  knife. 

As  was  natural,  a  few  patients  improved  after  so  severe  a 
lesion  of  the  parts  more  or  less  concerned  in  the  affection. 
Phillips  states  the  proportion  at  only  five  per  cent,  an  esti- 
mate which  has  called  forth  the  remonstrances  of  more 
ardent  advocates  of  the  operation.  Allowing  for  exaggera- 
tion, the  method  of  Dieffenbach  —  the  bisection  of  the  root 
of  the  tongue  —  seems  to  have  been  followed  by  a  certain 
degree  of  success,  but  is  by  far  the  severest  operation. 

It  is  evident  that  the  machinery  of  articulation  has  not 
been  adequately  analyzed  with  reference  to  the  operation,  and 
that  the  indications  of  derangement  of  its  various  parts  have 
been  too  little  considered.     A  first  step,  then,  towards  the 


38  ORTHOPEDIC  SURGERY. 

study  of  this  affection  is  an  analysis  of  the  articulate  sounds, 
and  of  the  manner  of  their  production,  of  which  a  sketch 
proportioned  to  the  limits  of  this  essay  is  here  offered. 

The  mouth,  including  the  trachea  and  the  lips,  may  be  con- 
sidered as  divided  arbitrarily  by  four  diaphragms,  necessary 
to  articulation,  and  capable  of  intercepting  both  wholly  or 
in  part  the  air  expelled  by  the  lungs.  The  first  of  these 
is  the  vocal  cords ;  the  second,  the  root  of  the  tongue ;  the 
third,  the  tip  of  the  tongue;  and  the  fourth,  the  lips.  To 
these  four,  each  by  itself  or  aided  by  the  nasal  cavity,  may 
be  referred  most,  if  not  all,  articulate  sounds. 

1.  The  vocal  cords,  by  their  vibration,  produce  the  voice. 
To  them  is  due  only  such  articulation,  if  we  may  so  call  it, 
as  is  produced  by  their  sudden  relaxation,  when  it  coincides 
with  an  expulsive  effort  of  the  lungs,  —  an  effort  termed  by 
elocutionists  exploding.     They  antagonize  one  another. 

2.  The  root  of  the  tongue  is  opposed  by  the  soft  palate, 
and  the  posterior  extremity  of  the  hard  palate,  as  in  k. 

3.  The  tip  of  the  tongue  is  antagonized  by  the  front  upper 
teeth,  and  by  the  bony  palate,  as  t  in  the. 

4.  The  lips  are  opposed,  either  one  to  the  other,  or  the 
lower  one  to  the  upper  front  teeth,  as  in  jo,  ph. 

Sounds  are  modified  by  two  conditions  of  each  articulating 
isthmus;  when  shut,  and  when  partially  opened.  Thus,  with 
the  lips,  as  in  p  and  in/;  with  the  tip,  as  in  t  and  in  th ; 
with  the  root,  as  in  k  and  in  ch  in  the  German  nicht.  The 
same  sounds  are  modified  by  the  addition  of  the  voice  thus: 
without  the  voice,  as  \n  p ;  with  the  voice,  as  in  h  ;  so  also 
in  t,  (7,  7r,  and  g  hard. 

A  third  and  last  alteration  of  the  same  sounds  is  effected 
by  the  opening  of  the  nasal  cavities,  by  which  h  becomes  wi, 
d  becomes  w,  and  g  hard  becomes  ng. 

Such  are  the  regular  principles  of  articulation.  To  these 
may  be  added  three  exceptional  and  irregular  soimds,  pro- 


STAMMERING. 


39 


duced  by  the  tip  of  the  tongue  against  the  hard  palate:  a 
whistle  analogous  to  the  whistle  of  the  lips,  as  in  s,  and  a 
little  farther  back,  sh  ;  the  sound  of  Z,  produced  by  the  lat- 
eral application  of  the  tip  and  edge  of  the  tongue  to  one  side 
of  the  hard  palate,  while  the  air  passes  by  the  other  side ; 
and  the  vibration  of  the  flexible  extremity  in  the  letter  r. 
This  sketch  may  be  condensed,  as  in  the  following  table. 


Lips 

Tip  of  Tongue 

Root  of  Tongue 

shut 

partly 
opeu 

shut 

partly  open 

ir 

shut 

partly  open 

regular 

irregulr 

hissing 

With 
voice 

b 

(1) 

V 

d 
n 

(2) 

th-ough 

z,  j  [French) 

(4) 

r 

(51 
1 

g  hard 

Nasal 

m 

ug 

Without 
voice 

P 

f,  ph 

t 

th-ing 

s,  sh 

k,  q 

eh  in  nacnt 

(1)  The  letter  v,  though  formed  between  the  front  upper 
teeth  and  the  under  lip,  is  identical  with  the  sound  produced 
by  a  slight  separation  of  the  lips,  as  in  the  Spanish  Hahana^ 
pronounced  like  the  English  Havana,  though  formed  by  the 
lips.     In  the  latter  case  it  is  somewhat  exaggerated. 

(2)  Were  the  palate  flat,  it  is  probable  the  sound  tJi  would 
be  produced  by  the  position  of  the  tongue  which  now  forms  s, 
to  avoid  which  its  extremity  is  advanced  to  the  teeth. 

(3)  The  concavity  of  the  palate,  with  the  similar  opposing 
one  of  the  tongue,  produces  the  whistling  s  and  z.  A  short 
distance  farther  back  it  is  more  diffused,  and  becomes  the 
hissing  sh,  and  French/  as  in  jarret. 

(4)  That  r  is  a  vibration  is  shown  in  its  exaggeration  in 
the  Italian  language,  thus :   giorno,  aver  for  avire. 


40  ORTHOPEDIC  SURGERY. 

(5)  The  sound  of  Z  is  irregular,  produced  by  a  partial  but 
firm  interception  of  the  current  of  sound  by  the  tip  and  edge 
of  the  tongue  applied  to  the  palate. 

(6)  The  ch  in  the  German  nacht  is  perfectly  analogous  to 
pli  and  th  in  English. 

It  will  be  seen  that  this  table  refers  only  to  the  enunciation 
of  the  consonants,  which  may  be  considered  as  the  interrup- 
tions and  interceptions  of  the  vowels,  and  therefore  more 
immediately  concerned  in  the  defect  of  stammering.  The 
original  sound  produced  by  the  vocal  cords  is  modified,  but 
not  intercepted,  during  the  production  of  a  vowel.  A  com- 
plete interruption  occurring  after  the  sound  has  left  the 
larynx  forms  a  consonant. 

If  stammering,  in  its  common  forms,  be  a  spasmodic  con- 
traction of  the  muscles  concerned  in  the  mechanism  of  artic- 
ulation, it  is  probable,  although  direct  proof  is  wanting,  that 
it  may  exist  at  either  of  the  four  points  already  mentioned, 
and  that  each  may  be  the  seat  of  a  variety  of  the  affection, 
which  it  becomes  important  to  distinguish  from  the  rest. 
Some  indication  of  the  character  of  the  affection  may  be 
drawn  from  that  of  the  sounds  emitted.  But  this  is  an  un- 
certain test.  An  anterior  portion  of  the  mechanism,  if  de- 
ranged, will  be  liable  to  interfere  with  that  behind,  and  vice 
versa.  Thus  p  masks  ^,  and  t  interferes  with  the  articulation 
oi  p.  When,  in  confirmation  of  these  views,  we  witness  the 
varying  degrees  of  this  affection,  from  the  simple  lisp  to  the 
confirmed  stammer  accompanied  with  distressing  convulsions 
of  the  whole  countenance,  it  is  evident  that  the  lesion  is  a 
complicated  one,  and  that  in  its  different  forms  it  demands 
different  methods  of  treatment.  We  cannot  but  wonder, 
nevertheless,  at  the  temerity  of  surgeons,  who,  when  a  patient 
stammered,  at  once  condemned  him  to  the  knife,  and  indis- 
criminately divided  the  genio-glossi  muscles,  or  subjected  the 
entire  tongue  to  a  bloody  bisection,  with  the  vague  intention 
of  modifying  its  nervous  condition. 


STAMMERING.  41 

An  adjustment  of  the  machinery  of  articulation  can  be 
based  only  upon  a  thorough  analysis  of  its  complicated  ac- 
tion. An  outline  of  this  analysis  may  be  found  in  the  fore- 
going table,  and  such  must  be  the  groundwork  of  any  future 
efforts  to  identify  the  different  forms  of  this  affection. 

The  remainder  of  the  present  section  will  be  devoted  to  an 
account  of  the  different  operations  which  of  late  years  have 
been  practised  in  this  affection. 

HISTORY. 

The  Paris  "Journal  des  Debats  "  of  January  2,  1841,  con- 
tained the  following  original  announcement  of  the  operation 
of  Dieffenbach :  — 

"  We  read  in  a  German  paper  that  a  discovery  by  Profes- 
sor Dieffenbach  excites  general  attention  at  Berlin.  This 
surgeon  has  found  a  way  of  curing  stammering  by  an  in- 
cision of  the  tongue.  The  operation  he  performs  has  com- 
pletely succeeded.  According  to  Dieffenbach,  stammering 
arises  from  an  impossibility  of  applying  the  tongue  to  the 
palate.  His  method  consists  in  putting  an  end  to  this 
disability." 

These  intimations  were  not  lost  upon  the  French  surgeons. 
Some  of  them  laid  claim  to  previous  verbal  suggestions  of 
an  operation.  Others,  adopting  the  principles  hinted  at  by 
Dieffenbach,  sought  to  discover  his  procedure ;  and  hence 
resulted  what  is  known  as  the  French  operation.  It  was 
announced  nearly  simultaneously  by  Amussat,  Phillips, 
Baudens,  and  Velpeau.  It  subsequently  appeared,  however, 
that  the  surgeon  of  Berlin  employed  a  different  method. 
With  the  intention  at  once  of  enabling  the  patient  to  an- 
tagonize the  tongue  with  the  roof  of  the  mouth,  and  of 
"changing  the  innervation,"  he  practised  a  deep  transverse 
section,  sometimes  with  a  subtraction  of  substance,  at  the 
root  of  this  or2:an. 


42  ORTHOPEDIC  SURGERY. 

The  French  method  had  reference  only  to  the  liberty  of 
the  tip  of  the  tongue,  and  consisted  in  the  division  of  the 
genio-glossal  muscles  and  other  parts  beneath. 

The  different  French  operations  are  essentially  the  same, 
and  the  literature  of  this  subject  relates  chiefly  to  the  opera- 
tion, and  is  for  the  most  part  polemic  in  its  character. 

METHODS    OP    DIEFFENBACH. 

The  theories  upon  which  Dieffenbach  founded  his  operation 
are  explained  in  the  following  quotations. 

Shortening  of  the  Muscular  Substance.  —  "  It  is  especially 
upon  this  last  method  [excision  of  a  portion  of  the  tongue] 
that  I  have  founded  the  greatest  hope,  because  it  had  for 
its  result  the  shortening  of  the  tongue,  and  enabled  it  to 
touch  the  superior  wall  of  the  buccal  cavity;  a  movement 
the  execution  of  which  is  especially  sought.  .  .  .  The  pa- 
tient, after  operation,  has  a  sensation  of  a  shortening  of 
the  tongue,  and  of  an  elevation  of  its  point  against  the 
palate. "  ^ 

Change  of  Innervation.  — "  As  I  thought  that  the  de- 
rangement in  the  mechanism  of  language  which  produces 
stammering  had  a  dynamic  cause,  and  regarded  it  as  a 
spasmodic  state  of  the  air  tubes,  situated  especially  in 
the  glottis,  which  was  communicated  to  the  tongue,  to  the 
muscles  of  the  face,  and  even  to  the  neck,  I  concluded 
that,  by  interrupting  the  innervation  in  the  muscular  parts 
which  participate  in  this  abnormal  state  I  should  succeed 
in  modifying  it,  or  in  causing  its  complete  cessation. 

"It  is  for  this  reason  that  the  transverse  section  of  the 
muscular  substance  of  the  tongue  seemed  to  be  an  enter- 
prise worthy  of  being  attempted,  and  of  which  the  suc- 
cess  promised   to   be    infallible,    equalling   in   efficacy   the 

1  Dieffenbach,  in  the  Annales  rle  la  Chirurgie  Fran^aise  et  fitrangere, 
Paris,  1841,  torn.  i.  pp.  422  and  436. 


STAMMERING.  43 

transverse  section  of  muscles  in  a  great  number  of  spas- 
modic affections." 

To  accomplish  these  ends,  Dieffenbach  employed  succes- 
sively three  different  methods :  — 

A  horizontal  transverse  section  of  the  root  of  the  tongue. 

A  subcutaneous  transverse  section  of  the  root  of  the  tongue, 
preserving  the  mucous  coat. 

A  horizontal  section  of  the  root  of  the  tongue  in  its  entire 
breadth  and  thickness,  with  excision  of  a  triangular  piece.  ^ 

Method  of  Excision.  —  The  patient  is  seated,  his  head  sup- 
ported against  the  chest  of  an  assistant.  The  tongue  is  pro- 
truded and  seized  upon  its  edge  by  the  teeth  of  a  pince  de 
Museux.  Thus  laterally  compressed  it  gains  in  thickness, 
a  condition  favorable  to  the  operation.  Being  then  carried 
forward  and  a  little  to  the  right,  by  one  aid,  while  another 
draws  apart  the  angles  of  the  mouth  with  blunt  hooks,  the 
root  is  seized  by  the  thumb  and  forefinger  of  the  operator's 
left  hand,  laterally  compressed,  and  raised.  The  blade  of  a 
bistoury,  edge  upward,  is  entered  at  the  left  side  of  the  root, 
penetrates  to  the  opposite  surface,  and  cuts  its  way  out  from 
below  upward.  The  posterior  edge  of  the  wound  being 
fixed  by  a  stout  ligature,  the  anterior  border  is  seized  with 
toothed  forceps,  laterally  compressed,  and  cut  off  with  a 
narrow  bistoury.  The  piece  thus  removed  is  wedge-shaped, 
the  base  about  three  fourths  of  an  inch  in  breadth,  corre- 
sponding to  the  mucous  surface,  and  has  been  compared  to  a 
slice  of  melon.  The  posterior  edge  is  then  brought  forward, 
by  means  of  the  ligature  and  a  small  hook,  and  united  to  the 
anterior  edge  by  six  strong  points  of  suture,  which,  travers- 
ing the  bottom  of  the  wound,  impede  hemorrhage. 

In  subsequently  removing  the  first  ligature,  if  it  be  followed 
by  an  oozing  of  blood,  it  is  an  announcement  that  the  cicatri- 
zation is  not  yet  solid,  and  the  surgeon  should  desist.     This 

1  Lettre  a  I'Academie  Royale  des  Sciences,  printed  at  Berlin. 


44  ORTHOPEDIC   SURGERY. 

fact,  and  the  manner  of  arresting  the  hemorrhage  by  deep 
sutures  embracing  the  mass  of  the  tongue,  may  serve  as 
hints  for  other  operations  upon  these  parts. 

The  Simple  Section  of  the  Boot  of  the  Tongue  resembles 
the  preceding  method,  without  the  removal  of  the  wedge- 
shaped  mass. 

Subcutaneous  Section  of  the  Root  of  the  Tongue.  —  In  this 
operation,  the  upward  section  terminates  before  dividing  the 
mucous  coat  upon  the  superior  surface  of  the  tongue. 

Dieffenbach  thus  speaks  of  the  dangers  of  the  operation: 
"  The  loss  of  the  tongue  by  gangrene  or  by  extensive  sup- 
puration, or  even  by  a  lack  of  dexterity  of  the  assistant, 
who  may  easily  tear  it,  are  considerations  which  require  to 
be  maturely  weighed,  and  which,  joined  to  the  difficulties 
which  it  presents,  will  hinder  operators  of  little  experience 
from  wishing  to  attempt  it. " 

FRENCH    OPERATION. 

The  propositions  of  the  French  surgeons  embraced  the  prin- 
cipal points  presented  by  Dieffenbach.  The  conditions  sup- 
posed to  accompany  stammering,  indiscriminately  in  all  its 
varieties,  are  thus  enumerated :  — 

Slight  deviation  of  the  tongue  to  the  right  or  left. 

Impossibility  of  pressing  the  tip  of  the  tongue  against  the 
upper  lip  without  the  aid  of  the  lower  jaw,  which  advances 
to  support  it. 

Spasmodic  agitation  of  the  tongue  during  the  act  of 
phonation. 

To  these  Velpeau,  Amussat,  and  others  added  a  fourth 
proposition :  — 

A  remarkable  development  of  the  genio-glossal  muscles, 
the  frenum  being  strong  and  hard. 

The  division  of  these  muscles  is  the  aim  of  the  French 
operation.     The  different  methods  are  subjoined. 


STAMMERING.  45 

Method  of  Phillips.  —  The  patient  is  seated,  as  in  the 
operation  of  Dieffenbach.  The  surgeon  seizes  the  frenum  at 
its  angle  of  reflection  upon  the  tongue  with  a  hook,  bent  at 
right  angles  that  it  may  not  impede  his  subsequent  manipu- 
lations, and  confides  it  to  an  aid.  He  then  implants  a  second 
small  hook  in  the  frenum,  at  a  half-line  distance  from  the 
ducts  of  Wharton,  and  between  the  two  hooks  divides  largely 
the  mucous  coat,  with  scissors.  Laying  aside  the  scissors, 
he  introduces  by  the  wound  a  blunt  hook  edged  upon  its 
concavity,  and,  collecting  upon  it  "  all  the  muscular  mass  of 
the  tongue,"  divides  it  with  a  sweep  of  the  instrument. 

Phillips,  it  is  seen,  severs  the  muscle  near  its  fan-like 
expansion  in  the  tongue.  The  other  methods  deal  with  a 
point  nearer  the  jaw,  where  the  muscle  is  less  voluminous 
and  less  vascular. 

Methods  of  Velpeau.  —  The  tongue  is  held  by  the  left  hand, 
armed  with  a  linen  cloth,  and  drawn  aside.  A  puncture  is 
made  with  a  lancet  at  the  right  of  the  frenum  near  the  un- 
der jaw.  A  tenotome  is  plunged  in  the  aperture  to  the 
depth  of  three  fourths  of  an  inch,  and  the  genio-glossal 
muscles  are  divided  without  enlarging  the  incision  of  the 
mucous  membrane. 

In  another  case  the  section  was  made  with  scissors. 

In  a  third  patient  M.  Velpeau  removed  a  triangular  mass 
from  the  point  of  the  tongue,  and  the  wound  was  brought 
together  by  sutures. 

In  a  fourth,  the  anterior  pillar  of  the  velum  palati,  which 
contains  the  palato-glossus  muscle,  was  divided,  but  without 
success. 

At  a  subsequent  operation  this  surgeon  strangulated  by 
ligature  a  mass  resembling  in  size  and  position  the  wedge 
removed  in  the  operation  of  Dieffenbach.  The  tongue,  being 
drawn  forward,  was  traver&ed  at  its  root  by  a  needle  armed 
for  streno;th  with  four  threads.     Two  were  tied  over  the  back 


46  ORTHOPEDIC  SURGERY. 

of  the  tongue.  The  two  others  were  tied  in  the  same  way, 
a  little  in  advance  of  the  first,  thus  insulating  a  portion  of 
the  tissues  which  subsequently  sloughed  away. 

Method  of  Amussat.  —  The  surgeon  first  divides  the 
frenum  with  the  mucous  membrane  on  each  side,  and  the 
salivary  glands,  avoiding  the  ducts  of  Wharton.  If  no 
advantage  is  gained,  the  genio-glossal  muscles  are  divided 
near  the  apophyses.  If  during  this  process  the  tongue  be 
thrust  forward  and  upward,  the  muscles  spontaneously  offer 
themselves  for  section,  and  are  easily  divided  with  knife  or 
scissors. 

Method  of  Bauderis.  —  This  surgeon  employs  pointed  scis- 
sors bent  at  an  elbow  near  the  pivot,  like  Roux's  scissors 
for  the  operation  of  staphyloraphy.  Slightly  opened,  they 
are  thrust  to  some  depth  astride  the  genio-glossal  muscles, 
which  are  then  divided  at  a  single  stroke.  The  genio-hyoid 
muscles  are  sometimes  included  in  the  section. 

Method  of  Lucas,  of  London.  —  The  mucous  membrane  and 
cellular  tissue  are  dissected  to  the  extent  of  an  inch,  for  the 
purpose  of  exposing  and  avoiding  the  ranine  arteries,  the 
large  veins,  and  a  branch  of  the  lingual  nerve  which  borders 
the  outside  of  each  muscle.  The  muscles  arc  then  divided, 
and  a  triangular  fragment,  whose  base  corresponds  to  the 
surface,  is  detached. 

Subcutaneous  Operation.  —  M.  Bonnet  has  proposed  a  punc- 
ture beneath  the  chin,  at  the  distance  of  an  inch  behind  it. 
A  tenotome  is  introduced,  and  thrust  upward,  its  edge  to- 
ward the  bone.  When  it  is  perceived  beneath  the  mucous 
membrane  the  surgeon  feels  for  the  insertion  of  the  genio- 
glossal muscles  and  cuts  to  the  right  and  left.  By  keeping 
the  edge  of  the  tenotome  against  the  jaw  and  acting  only 
upon  the  superior  part  of  the  convexity  of  the  bone,  upon  a 
median  line,  the  insertions  of  the  genio-hyoid  muscles  are 
avoided. 


STAMMERING.  47 

ACCIDENTS   AFTER   THE   OPERATION. 

Hemorrhage. — The  vascularity  of  the  parts,  the  size  of 
the  incision,  and  the  difficulty  of  commanding  the  bleeding- 
vessels,  are  conditions  which  give  rise  to  formidable  hemor- 
rhage, arrested  with  difficulty  by  means  more  painful  than 
those  employed  to  remedy  the  stammering.  It  is  obviously 
difficult  to  gather  evidence  upon  this  point.  At  a  time  when 
surgeons  emulated  each  other  in  reporting  successful  results 
from  the  operation,  various  motives  induced  misrepresenta- 
tion. But  the  danger  of  hemorrhage  is  not  altogether  con- 
cealed. Dieffenbach  says  of  his  own  subcutaneous  method, 
"The  blood  gushed  with  abundance  from  the  two  lateral 
wounds,  as  if  it  escaped  from  a  large  arterial  trunk,  and  the 
tongue  soon  became  tumefied  by  the  mass  of  blood  which 
accumulated  in  the  interval  of  the  subcutaneous  section." 
The  books  allude  to  a  student  at  Berlin  operated  upon  by 
this  surgeon,  who  died  from  the  profuse  bleeding  attendant 
upon  the  operation. 

Phillips  says  of  the  operation,  "It  is  surrounded  with  too 
many  dangers  to  be  retained  in  practice.  The  hemorrhage 
is  always  very  abundant,  and  we  possess  no  means  to  arrest 
it,  unless  by  a  second  operation,  more  painful  and  more 
cruel  than  the  first. "  And  in  another  place,  "  The  hemor- 
rhage which  follows  this  operation  is  of  long  duration ;  and 
I  felt  the  greatest  anxiety  after  having  operated  upon  a 
young  man  of  Liege.  The  section  of  the  muscles  was  made 
at  eleven  o'clock  in  the  morning.  At  eight  o'clock  in  the 
evening  the  blood  still  flowed,  as  from  the  mouth  of  an  open 
artery. "  Again,  "  I  have  seen  patients  in  my  practice  lose 
blood  seven  or  eight  hours  after  the  operation,  without  the 
possibility  of  arresting  it." 

M.  Guersent,  surgeon  of  the  Hopital  des  Enfants,  has  pub- 
lished a  remarkable  case  of  this  kind,  in  which  the  patient, 


48  ORTHOPEDIC   SURGERY. 

a  child  of  twelve  years,  was  predisposed  to  hemorrhage. 
After  the  operation  by  Amussat's  method,  the  hemorrhage 
commenced,  and  was  renewed  at  intervals  for  ten  days. 
During  this  time  every  means  were  employed  to  arrest  the 
bleeding,  —  styptics,  balls  of  charpie,  cold  lotions,  and  finally 
the  actual  cautery,  which  was  renewed  seven  times.  At 
the  end  of  ten  days  the  patient  presented  a  state  of  almost 
complete  anaemia,  from  which  it  slowly  recovered.  At  the 
end  of  three  weeks  the  child  stammered  as  before,  the  tongue 
being  much  shorter  after  the  operation. 

The  bleeding  is  promoted  by  the  inclination  which  patients 
have  to  suck  blood  from  the  wound. 

The  hemorrhage  should,  in  common  cases,  be  treated  by 
the  injection  of  iced  water,  tamponnetnenf,  or  plugging  with 
balls  of  lint  wet  with  alum  or  some  other  styptic  solution. 
In  the  operation  of  Dieffenbach,  the  bleeding  is  counteracted 
by  deep  sutures,  which  are  drawn  tight,  thus  compressing  the 
mass  of  the  tongue.  The  hemorrhage  is  usually  arrested 
by  the  formation  of  a  more  or  less  voluminous  clot,  which 
should  not  be  disturbed.  Phillips  alludes  to  two  cases  of 
obstinate  hemorrhage  following  the  removal  of  the  coagulum. 

Tumefaction  of  the  Toyigue.  —  The  engorgement  of  the 
tissues,  often  considerable  during  the  inflammatory  action, 
is  sometimes  such  as  to  hazard  the  life  of  the  patient. 

"Everybody  knows  the  deplorable  story  of  a  young  man 
operated  upon,  whose  tongue  acquired  a  considerable  volume. 
It  formed  upon  the  lower  wall  of  the  mouth  a  vast  valve. 
During  the  night,  the  symptoms  became  more  and  more 
alarming,  and  the  result  was  finally  enveloped  in  a  profound 
mystery.  How  many  other  examples  have  had  the  same 
fate ! "  1 

In  the  "  Gazette  des  Hopitaux  "  (Juin  1,  1841)  M.  Amussat 
has  avowed  one  case  of  death.     The  subject  had  been  operated 
1  Phillips,  Tenotomie  Souscutanee,  p.  392. 


STAMMERING.  49 

upon  in  presence  of  a  commission  named  by  the  Academy. 
The  same  journal  contains  also  the  history  of  a  man  who 
came  near  dying  of  asphyxia  by  the  enlargement  of  the 
tongue. 

The  tongue,  left  to  itself  after  the  section  of  the  genio- 
glossal muscles,  exercises  a  great  force  of  retraction,  and 
has  a  tendency  to  turn  back  upon  the  glottis,  an  accident 
which  it  has  been  shown  may  be  fatal.  A  similar  accident 
is  to  be  apprehended  from  the  posterior  portion  of  the  tongue 
in  the  transverse  dorsal  incision  of  Dieffenbach,  and  hence 
the  care  requisite  to  secure  it  during  the  operation  by  means 
of  a  ligature  or  a  hook  passed  through  its  substance. 

APPRECIATION   OF   THE   DIFFERENT  METHODS. 

In  estimating  the  comparative  value  of  the  different 
methods,  a  first  ground  of  comparison,  unquestionably  the 
most  important,  is  their  efficiency  in  relieving  the  imperfec- 
tion of  articulation.  The  inadequacy  of  the  operation  in  a 
majority  of  cases  seems  generally  to  be  conceded.  It  has 
been  shown  that,  by  its  application  to  a  part  only  of  the 
articulating  machinery,  it  is  theoretically  incomplete.  But 
such  an  admission  is  not  to  be  looked  for  in  papers  upon  this 
subject,  the  aim  of  most  of  which  is  to  herald  the  success  of 
a  new  operation,  and  to  give  notoriety  to  its  advocates. 

To  this  remark  there  are  exceptions.  Dieffenbach  con- 
siders the  operation  inapplicable  in  certain  cases,  and  also 
concedes  that  "  the  indications  "  of  the  operation  are  much 
more  difficult  to  determine  than  in  the  operation  for  stra- 
bismus. 

Of  the  French  operation  Phillips  thus  speaks:  "Among 
true  stammerers  there  are  some  who  redouble  the  b,  p,  d,  f, 
and  who  pronounce  for  example  b,  b,  b,  b,  a,  etc.  These 
may  be  improved  by  the  section  of  the  genio-glossi,  but  not 
radically   cured;   the  lips  play  a  too   considerable  role  in 

4 


50  ORTHOPEDIC   SURGERY. 

the  articulation  of  these  letters.  Those  who  redouble  the  t 
and  the  a  may  be  radically  cured  by  the  section  of  the  genio- 
glossi,  if  there  is  not  at  the  same  time  some  defect  in  the 
respiration.  Stammering  upon  s  and  z  may  be  also  dimin- 
ished by  the  operation ;  but  if  it  bears  upon  the  h,  k,  and  w, 
the  operation  is  without  effect.  I  have  never,  up  to  the 
present  day,  been  able  to  appreciate  the  least  change  upon 
these  letters  after  the  operation. " 

These  observations  are  cited  as  Confirming  the  analysis  of 
sounds  laid  down  by  the  writer  in  the  beginning  of  this 
section. 

The  articulation  of  the  consonants  mentioned  by  Phillips, 
as  affected  by  the  section  of  the  genio-glossi,  will  be  found  re- 
ferred in  that  table  to  the  tip  of  the  tongue,  and  consequently 
directly  influenced  by  the  liberty  of  that  part  of  the  organ. 

M.  Chassaigne,^  another  writer  upon  this  subject,  in 
opposing  this  theory  of  Phillips,  cites  a  case  in  which  the 
pronunciation  of  the  sentence  Maman  m'a  mande  was  facili- 
tated by  the  section  of  the  genio-glossi.  It  is  probable  that 
in  this  case  the  affection  existed,  not  in  the  labial  muscles, 
but  in  those  of  the  tip  of  the  tongue,  the  spasmodic  action 
of  which  masked  or  impeded  the  labial  articulation.  Such 
mistakes  have  arisen  from  an  insufficient  study  of  the  varie- 
ties of  the  affection.  In  most  reported  cases,  it  sufficed  that 
the  patient  was  unable  to  articulate  certain  test  words,  like 
those  alluded  to,  or  "Kakoski,  Colonel  des  Cossaques," 
"hippopotamus,"  "concupiscence,"  and  he  became  a  subject 
for  the  operation,  according  to  the  method  then  in  vogue. 
If  after  this  lesion  of  the  buccal  cavity  the  spasmodic  action 
of  the  muscles  ceased  for  a  time,  the  operation  was  proclaimed 
satisfactory  in  its  result.  Such  has  been  the  assertion  after 
operations  I  have  often  witnessed  in  the  Paris  hospitals,  and 
in  the  majority  of  printed  observations. 

1  Traite  du  Strabisme  et  du  Begaiement,  Paris,  1841,  p.  140. 


STAMMERING.  51 

Authors  seem  to  accord  to  Dieffenbach  a  greater  share  of 
success  than  to  other  surgeons.  No  means  of  estimating 
the  value  of  his  assertions  upon  this  point  are  at  hand.  It 
is  however  difficult  to  give  full  credit  to  statements  like  the 
following :  "  I  have  within  a  short  time  operated  upon  four- 
teen stammerers  by  removing  a  triangular  piece  of  the  tongue, 
and  in  all  the  stammering  has  entirely  ceased. "  ^  It  may  be 
suspected  that  at  the  end  of  a  longer  period  it  returned,  at 
least  in  some  of  the  cases. 

It  is  easy  to  imagine  that,  in  promiscuous  operations  upon 
the  different  varieties  of  the  affection,  the  section  of  Dief- 
fenbach, which  involves  all  the  lingual  muscles,  should  more 
readily  alter  the  functional  conditions  of  the  tongue  than 
the  division  of  the  genio-glossi  alone.  But  if  the  division 
of  muscles  be  its  object,  this  method  attacks  indiscriminately 
the  interweaving  fibres  of  all  the  fasciculi,  without  bearing 
directly  upon  the  body  of  any  one  of  them.  On  the  other 
hand,  it  is  difficult  to  establish  how  far  it  may  alter  the  in- 
nervation of  the  tongue :  neither  is  this  proved  to  be  the 
essential  end  of  the  operation.  If  the  previous  length  of  the 
lingual  surface  interfered  with  the  power  of  opposing  the  tip 
to  the  palate,  the  removal  of  a  portion  of  the  dorsum  might 
tend  to  obviate  this  difficulty ;  but  much  less  directly  than 
the  division  of  the  genio-glossal  muscles. 

Until  the  applicability  of  the  German  operation  be  clearly 
indicated,  and  its  efficacy  shown,  the  profuse  and  dangerous 
hemorrhage,  the  tumefaction,  and  other  inflammatory  acci- 
dents to  which  it  is  liable,  are  insurmountable  objections 
to  its  performance. 

The  same  is  true  in  a  less  degree  of  the  French  method, 
which,  however,  probably  applies  to  a  greater  number  of 
cases,  and  is  least  objectionable  when  the  point  of  section 
approaches  the  jaw  bone,  as  in  the  subcutaneous  section  of 

1  Dieffenbach,  Gazette  des  Hopitaux,  18  Mars,  1841. 


52  ORTHOPEDIC  SURGERY. 

Bonnet,  which  is  confined  to  the  tendinous  insertions  of  the 
muscles.  The  analogy  of  this  method  to  the  simjtle  section 
of  the  frenum  in  tongue-tied  children  is  obvious.  It  is 
sometimes  employed  with  advantage  where  the  tongue  is  not 
confined,  but  where  the  spasmodic  condition  of  the  genio- 
glossi  muscles  can  be  clearly  demonstrated. 

The  method  of  Velpeau,  by  ligature,  offers  a  smaller  chance 
of  hemorrhage,  but  is  even  more  subject  to  violent  inflamma- 
tory accidents.  The  removal  of  a  triangular  mass  from  the 
anterior  part  of  the  tongue  and  from  the  genio-glossal  muscle, 
the  division  of  the  genio-hyoid,  and  other  equally  fanciful 
sections,  are  evidently  experimental. 

Authentic  statistics  in  regard  to  these  different  operations 
will  not  be  expected  when  the  unscientific  character  of  most 
of  the  papers  upon  this  subject  is  considered.  The  following 
figures,  those  of  Dieffenbach  excepted,  refer  to  the  French 
method. 

M.  Baudens  says,  "  We  count  at  this  time  twenty-one  per- 
sons operated  upon  by  our  method.  All  have  obtained,  if 
not  an  absolute  cure,  a  notable  amelioration."  It  is  suf- 
ficient to  add,  that  in  regard  to  strabismus  the  same  author 
remarks,  "  In  eight  hundred  squints  that  we  have  operated 
upon  ...  we  have  succeeded  in  every  instance ;  let  scep- 
tics put  us  to  the  test ;  let  them  give  us  the  most  desperate 
cases,  and  when  we  have  failed  once,  we  will  yield  to  the 
evidence. "     Such  assertions  need  no  comment. 

Dieffenbach  has  just  been  quoted  as  having  operated  upon 
fourteen  patients,  in  all  of  whom  the  stammering  had  en- 
tirely ceased. 

Chassaigne,  of  seventeen  cases,  gives  seven  cured,  five 
ameliorated,  and  five  with  no  beneficial  result. 

Finally,  Phillips  concludes  his  essay  as  follows :  — 

"Of  one  hundred  individuals  speaking  badly,  and  im- 
properly called  stammerers,  we  find  only  five  subjects  who 


TENOTOMY.  53 

really  stammer,  and  who  can  be  operated  upon  with  success. 
Of  these  five  individuals,  three  stammer  only  upon  the 
lingual  letters.  In  such  cases  the  operation  is  striking  in 
its  results ;  the  stammering  ceases  entirely.  The  other  two 
stammer  upon  Unguals  and  labials,  and  then  the  operation 
affects  the  stammering  of  the  Unguals  alone  and  hardly 
modifies  that  of  the  labials. 

"  I  have  seen  in  the  service  of  M.  Yelpeau  a  case  of  bril- 
liant success  after  an  operation  upon  a  subject  who  stam- 
mered, i.  e.  redoubled  the  Unguals. 

"The  ninety-five  other  individuals  do  not  stammer,  but 
speak  defectively;  either  because  they  shut  the  mouth  in 
trying  to  talk,  or  because  they  do  not  breathe,  or  because 
they  cannot  or  do  not  know  how  to  make  use  of  the  tongue 
to  aid  articulation,  or  finally  because  they  have  nothing  to 
say." 

TENOTOMY. 

The  division  of  tendons  is  an  operation  of  ancient  date. 
Tulpius,  in  1685,  refers  to  Isacius  Minius  as  having  practised 
it.  It  was  at  that  time  considered  a  grave  and  dangerous 
procedure,  and  De  la  Sourdiere,  in  1742,  concludes  a  memoir 
in  the  following  words  :  "  The  section  of  tendons  ought  then 
to  be  avoided."  In  1782  or  1784  Lorenz  divided  the  tendo 
Achillis  at  the  request  of  Thilenius,  a  physician  of  Frankfort ; 
and  Michaelis  soon  after  effected,  though  incompletely,  the 
same  section. 

Until  recently,  it  was  the  custom  of  surgeons  to  incise 
the  integuments  with  the  tendon,  the  severed  extremities  of 
which  were  freely  exposed  to  the  air.  In  these  conditions, 
the  divided  tendinous  surfaces  remain  for  a  length  of  time 
pale.  Slowly  they  become  vascular,  granulate  until  the 
vegetations  fill  the  surrounding  void,  and  finally  heal,  with 


54  ORTHOPEDIC  SURGERY. 

a  dense  firm  cicatrix,  which  involves  cellular  tissue,  aponeu- 
roses, and  integuments.  The  sliding  of  the  tendon  is  thus 
impeded,  and  in  its  restricted  movement  it  carries  with  it  the 
surrounding  and  adhering  tissues.  The  restorative  process  is 
in  such  circumstances  tedious,  and  the  constitutional  reaction 
and  consequent  hazard  to  the  patient  considerable. 

At  the  present  day,  the  division  of  tendons  is  a  trifling 
operation,  and  almost  devoid  of  danger. 

Delpech  first  proposed  a  section  w^hich  should  not  denude 
the  tendon.  A  bistoury  was  passed  beneath  the  skin,  which 
it  traversed  at  two  points,  as  if  for  the  passage  of  a  seton. 
The  incision  was  extended  to  the  length  of  about  an  inch,  and 
the  tendon  was  divided. 

Stromeyer,  and  befoi'e  him  Dupuytren,  according  to  Velpeau, 
indicated  the  method  by  simple  punctures.  The  latter  surgeon 
confined  himself  to  a  single  orifice,  which  gave  admission  to 
the  instrument,  taking  care  not  to  wound  the  integument  of 
the  opposite  surface.  This  is  essentially  the  method  of  the 
present  time,  and  the  most  simple  which  science  now  pos- 
sesses. It  has  undergone  two  modifications,  referred  respect- 
ively to  Stoess  and  Bouvier. 

In  the  method  of  Stoess,  the  knife  is  introduced  beneath 
the  tendon,  which  is  divided  from  within  outward.  Bouvier 
enters  the  instrument  beneath  the  skin,  and  divides  the  tendon 
from  the  surface  toward  the  deep-seated  parts. 

The  field  of  subcutaneous  operations,  effected  by  a  simple 
puncture  of  the  integuments,  and  applied  to  muscles  and 
aponeuroses  as  well  as  tendons,  has  been  widely  extended 
by  various  surgeons,  among  whom  Dieffenbach  and  Guerin 
are  conspicuous.  The  exclusion  of  air  is  the  aim  and 
characteristic  of  this  method.  A  degree  of  vitality  is  thus 
retained  in  the  injured  parts,  and  even  in  the  effused  blood, 
which  favors  in  a  remarkable  manner  their  reparative  action. 
The  functions  of  absorption  and  secretion  are  carried  on  with 


TENOTOMY.  55 

a   rapidity   to   which   the   presence  of   the   atmospheric   air 
seems  fatal. 

An  entirely  new  class  of  operations  by  this  method  has 
sprung  into  existence,  to  which  the  continuation  of  this  essay 
will  be  devoted. 

SUBCUTANEOUS   CICATRIZATION   OF   DIVIDED   TENDONS. 

It  is  well  known  that  a  tendon,  when  divided  beneath  the 
skin,  is  disposed  to  retract,  leaving  an  interval  between  its 
extremities  at  the  point  of  section.  In  most  cases  the  inter- 
val is  obliterated,  and  the  continuity  of  the  tendon  re-estab- 
lished by  the  gradual  deposition  of  an  intermediate  fibrous 
tissue.  Observers  differ  with  regard  to  the  manner  in  which 
this  tissue  is  formed,  and  experiments  have  led  to  apparently 
contradictory  results. 

Stromeyer,  in  attributing  the  deformity  of  certain  club-feet 
to  muscular  contraction,  asserts  that  the  length  of  the  newly 
formed  tendon,  which  he  compares  to  a  thick  ring,  is  alone 
insufficient  to  account  for  the  rectification  of  the  deformity ; 
and  supposes  that  the  muscle,  once  relieved  from  the  stimulus 
of  tension,  elongates  itself  until  the  divided  tendinous  sur-' 
faces  are  brought  into  contact.  On  the  other  hand,  it  may  be 
urged  that  the  interposed  mass  is  often  considerable.  In  one 
experiment  of  Bouvier  its  length  was  nearly  two  inches  at 
the  end  of  twenty-four  days.  It  is  possible  that  the  tendinous 
end,  enlarged  at  its  point  of  union  with  the  newly  deposited 
matter,  may  have  been  mistaken  by  this  surgeon  for  the  en- 
tire substance  of  the  cicatrix. 

One  class  of  observers,  among  whom  are  Held  and  Bouvier, 
suppose  that  the  tendinous  sheath,  with  its  surrounding  cellu- 
lar tissue,  undergoes  a  gradual  transformation  into  fibrous 
matter,  with  agglutination  of  its  walls  and  obliteration  of  its 
cavity.  Others,  leaning  to  the  theory  of  Hunter,  assert  that 
the  cavity  of  the  sheath  is  a  receptacle  of  blood  and  of  lymph, 


56  ORTHOPEDIC  SURGERY. 

which  is  afterwards  organized  and  converted  into  tendinous 
fibre.     Such  are  Ammon,  Guerin,  Phillips,  and  Duval. 

The  results  of  the  detailed  experiments  of  Bou\der  ^  on  one 
side,  and  Ammon  ^  on  the  other,  render  it  probable  that  the 
restorative  action  varies  in  different  circumstances,  and  ac- 
commodates itself  to  the  pathological  conditions  of  the  parts. 
In  the  experiments  of  Ammon  the  effusion  of  blood  was  con- 
stant, and  was  probably  due  to  a  laceration,  more  or  less 
extended,  of  the  fibrous  envelope  and  surrounding  cellular 
tissue.  Hemorrhage  was  of  rare  occurrence  in  the  cases  of 
Bouvier;  and  we  infer  that  care  was  taken  to  divide  the 
tendon  without  injury  to  the  neighboring  parts.  Whether 
with  Guerin  we  consider  the  effused  coagulum  to  be  a  con- 
dition essential  to  the  process  of  restoration,  or  with  Velpeau 
regard  it  as  an  accidental  complication,  it  is  evident  that 
such  a  body  of  fibrine,  interposed  between  the  divided  tissues, 
must  modify  the  process  which  nature  sets  up  where  no 
such  extraneous  matter  exists. 

The  experiments  alluded  to  seem  to  establish  the  following 
propositions. 

When  the  tendinous  sheath  is  little  injured,  and  there  is 
a  free  communication  between  the  divided  ends  of  the  ten- 
don, the  tissue  of  the  sheath  becomes  dense  and  indurated 
by  the  deposition  of  fibrous  matter,  and  layers  of  cellular 
tissue  are  successively  impacted  upon  its  exterior.  In  the 
mean  time  its  cylindrical  cavity,  strangulated  at  the  centre, 
gradually  contracts ;  lymph  is  exuded  in  its  interior ;  the 
extremities  of  the  tendon  assume  a  conical  form,  and,  uniting 
with  the  sheath,  the  whole  mass  finally  acquires  the  character 
of  a  dense  fibrous  cord. 

But  when  the  surrounding  tissues  are  divided,  and  a  coagu- 
lum is  deposited  in  the  wound,  —  when,  instead  of  the  fibrous 

1  Memoires  de  I'Academie  Royale  de  Medecine,  torn.  vii. 

2  Experiments,  torn.  i.  p.  155. 


TENOTOMY.  57 

sheath  ready  at  hand  to  be  converted  into  tendon,  a  foreign 
body,  as  it  were,  is  interposed  between  the  divided  surfaces,  — 
the  process  of  restoration  is  different.  While  the  wounded 
surfaces  exude  lymph,  the  coagulum  plays  the  chief  part  in 
the  formation  of  the  new  tendon.  It  becomes  gradually  or- 
ganized. Its  substance  is  penetrated  by  vessels,  which  in 
their  turn  deposit  plastic  matter,  until  the  severed  extremi- 
ties are  at  length  united  by  a  few  filaments.  These  increase 
in  size,  acquire  a  compact  texture,  and  are  fused  in  time  into 
a  fibrous  resisting  mass. 

GENERAL   CHARACTERS   OF   DEFORMITY. 

It  is  probable  that  all  congenital  distortions  of  the  trunk 
and  limbs  are  the  result  of  muscular  contraction,  originally 
induced  by  an  affection  of  the  nervous  centre  or  its  branches. 

At  the  period  when  the  surgeon  is  called  upon  to  operate 
it  is  no  longer  active,  and  he  deals  only  with  results,  as  pre- 
sented by  certain  modifications  of  the  muscles,  fibrous  tissues, 
and  vessels. 

The  original  affection,  being  a  spasmodic  action  of  the 
muscular  fibre,  has  received  from  Guerin  the  name  of  "  con- 
traction "  ;  while  the  consequent  and  permanent  lesion,  as 
exhibited  in  the  partial  or  entire  change  of  the  muscular  into 
a  fibrous  tissue,  has  been  called  by  the  same  writer  "  retrac- 
tion." 1  The  duration  of  the  state  of  simple  contraction  is 
indefinite ;  and  during  this  period  the  soft  parts  may  be  elon- 
gated by  proper  means.  But  the  fibrous  change  is  attended 
with  rigidity,  unyielding  in  proportion  to  the  extent  of  the 
transformation. 

Most  cases  of  club-foot  present  these  characters,  and  date 
either  from  foetal  existence,  or  from  some  convulsive  affection 
of  early  life.     Their  leading  and  distinctive  feature  is  a  tense- 

1  To  this  condition  Little  has  applied  the  term  "structural  shorten- 
ing."    Lancet,  December  9,  1843,  p.  39. 


58  ORTHOPEDIC  SURGERY. 

ness  of  certain  tendons,  which  become  especially  evident  be- 
neath the  integuments  when  an  attempt  is  made  to  correct 
the  deviation.  They  are  then  rigid  and  salient,  and  mani- 
festly interfere  with  the  normal  position  of  the  limb. 

Retracted  muscles  are  generally  found  upon  dissection  to 
be  pale,  atrophied,  and  partially  converted  into  fibrous  tissue. 
They  are  more  or  less  completely  paralyzed,  and  their  de- 
velopment has  been  arrested.  The  fatty  transformation  is 
more  rare,  and  of  less  importance  to  the  surgeon.  It  has 
been  doubted  whether  it  be  possible  to  detect  this  lesion 
through  the  integuments.  When  it  interferes  with  the 
restoration  of  the  limb  to  a  normal  position,  it  is  generally 
more  or  less  combined  with  the  fibrous  change. 

Guerin  has  laid  down  two  rules  with  regard  to  the  change 
which  the  muscles  undergo  when  thus  permanently  contracted. 

In  all  chronic  deformities  the  muscles,  instead  of  continu- 
ing their  primitive  relations  with  the  distorted  portion  of  the 
skeleton,  tend  to  become  shorter  and  to  assume  a  straight 
line  between  their  two  points  of  insertion. 

The  transformation  of  muscles  is  fatty  or  fibrous ;  fatty, 
when  the  muscles  are  compressed  and  left  to  themselves ; 
fibrous,  when  they  are  submitted  to  exaggerated  traction.^ 

The  tendons  and  ligaments  seem  arrested  in  their  develop- 
ment rather  than  changed  in  form.  In  a  state  of  repose 
the  fibrous  cords  become  more  compact,  and  are  not  unfre- 
quently  converted  into  bony  matter.  Guerin  supposes  that 
this  osseous  deposition  only  occurs  when  the  muscles  become 
fatty  ;  but  the  position  has  been  disputed  by  other  surgeons. 

The  arteries  do  not  follow  the  muscles  in  their  deviation. 
They  are  neither  shortened  nor  tense  and  straight.  "  They 
accompany  the  muscular  curves  when  they  are  attached  to 
these  muscles,  and  become  tortuous  when  free ;  the  more  so 
when  the  distance  they  traverse  is  limited."  ^ 

1  Vues  Generales,  etc.,  Paris,  1840,  p.  23.  2  Qp^  cit.,  p.  25. 


TENOTOMY.  59 

The  nerves  tend  to  diminish  in  length  and  to  adapt  them- 
selves, like  the  muscles,  to  the  chord  of  the  curve  produced  by 
the  deformity.  This  disposition  to  retract  is  attributed  by 
Guerin  to  the  fibrous  tissue  of  the  neurilemma. 

The  vehis  dilate  and  increase  in  number,  —  modifications 
supposed  by  Guerin  to  explain  the  fatty  transformations  of 
the  tissues  in  general.  The  tendency  of  the  skeletons  of  de- 
formed limbs  to  exude  a  greasy  matter  is  well  known. 

INSTRUMENTS    AND    MANUAL    OF   THE    OPERATION. 

The  instruments  contrived  for  subcutaneous  operations  are 
exceedingly  numerous,  and  the  more  important  ones  will  be 
mentioned  in  another  place.  Many  of  them  offer  useless  com- 
plications and  refinements.  The  sections  may  all  be  effected 
with  one  or  two  tenotomes.  The  most  useful  consists  of  a 
blade  about  an  inch  in  length  by  one  eighth  of  an  inch  wide, 
pointed,  and  slightly  convex.  Attached  to  a  short  cylindrical 
shank,  it  serves  to  divide  the  larger  tendons.  Probe-pointed, 
straight  on  its  edge,  and  with  a  longer  shank,  it  may  be  used 
for  the  broad  or  deeper-seated  fibrous  tissues.     (Figs.  8,  9.) 

The  tension  of  tendons  is  by  far  the  most  important  indi- 
cation for  their  division.  When  it  is  ascertained  that  their 
retraction  interferes  with  the  normal  position  of  the  part,  it 
is  expedient,  as  a  general  rule,  to  divide  them ;  beginning 
with  the  most  rigid  and  salient. 

The  manual  of  the  operation  is  briefly  as  follows.  The 
region  being  placed  in  a  convenient  position,  the  tendon  to 
be  divided  is  made  tense,  and  if  possible  evident  beneath  the 
integuments.  This  is  effected  either  by  the  position  of  the 
patient,  by  voluntary  contraction  of  the  muscle,  or  by  external 
force  properly  directed. 

Guerin  pinches  up,  immediately  over  the  tendon,  a  fold  of 
skin,  one  end  of  which  is  confided  to  an  aid,  and  introduces 
the  tenotome  flatwise  at  its  base.     He  then  releases  the  in- 


60  ORTHOPEDIC  SURGERY. 

teguments,  and  the  puncture  recedes  to  a  distance  from  the 
])oint  of  section  while  the  blade  retains  its  position  near  the 
tendon.  The  tendon  is  now  made  tense  by  active  or  passive 
flexion  or  extension  and  divided  by  a  slight  sawing  movement 
of  the  knife. 

It  is  unimportant  whether  the  section  be  made  from  without, 
or  from  within  the  tendon,  if  there  be  no  especial  indication, 
such  as  the  neighborhood  of  large  vessels,  to  guide  the  opera- 
tor. A  place  of  section  should  be  chosen  where  the  tendon 
is  surrounded  by  cellular  membrane.  It  is  rarely  possible  to 
obtain  union  in  the  cavity  of  a  synovial  sheath ;  and  perma- 
nent deformity  has  resulted  from  division  of  the  tendon  in 
this  position. 

At  the  moment  the  section  is  completed  a  noise  is  heard  as 
the  two  ends  suddenly  recede  from  each  other,  which  is  modi- 
fied and  exaggerated  if  it  be  near  the  region  of  the  thorax. 
The  instrument  is  withdrawn  as  it  was  entered,  the  integu- 
ments being  compressed,  as  the  knife  recedes,  to  hinder  the 
admission  of  air.  As  the  blade  leaves  the  puncture  the 
finger  arrives  at  and  covers  it,  until  it  is  effectually  sealed 
by  a  bit  of  adhesive  plaster. 

HEMORRHAGE. 

If  the  hemorrhage  be  considerable  a  tumor  forms  at  the 
seat  of  the  effusion,  and  the  blood  should  be  expelled  through 
the  puncture  as  far  as  practicable.  It  is  most  frequently  dis- 
tributed in  the  cellular  membrane,  and  left  for  subsequent 
absorption.  Alarming  hemorrhage  is  rare,  as  the  larger 
vessels  are  not  involved  in  the  operation. 

In  some  experiments  of  M.  Amussat  which  I  saw  at  the 
Abattoir  Montmartre,  the  open  vessel,  even  when  of  con- 
siderable size,  if  completely  divided,  occupied  the  centre 
of  a  coagulum,  the  substance  of  w^hich  acquired  such  te- 
nacity as  to  confine  the  fluid  nucleus,  and  arrest  the  effu- 


TENOTOMY.  61 

sion.i  In  deep  sections  additional  security  is  offered  by  the 
flexibility  of  the  vessels,  which  yield  before  the  edge  of  the 
knife  while  the  resisting  tendon  is  divided.  Hence  it  is 
better  in  such  positions  to  avoid  as  far  as  possible  the  sawing 
movement  of  the  instrument,  and  to  divide  the  tendon  by 
pressure  perpendicularly  applied. 

MECHANICAL    TREATMENT. 

It  is  now  generally  allowed  that  an  immediate  application 
of  mechanical  force  is  not  indicated.  Inflammation,  re-open- 
ing of  the  puncture,  admission  of  air  and  suppuration,  were 
not  unfrequently  the  sequence  of  the  operation  in  past  years. 
These  accidents  have  become  less  common  since  attention 
has  been  directed  to  the  cicatrization  of  the  integuments 
before  beginning  the  mechanical  treatment. 

The  principle  of  the  various  machines  contrived  for  this 
purpose  is  simple.  Their  object  is  to  direct  and  maintain  a 
permanent  counteraction  against  the  curve  of  the  deformity. 
A  separate  part  of  the  apparatus  is  adjusted  to  each  detached 
portion  of  the  skeleton,  while  the  centres  of  movement  of 
the  machine  correspond  to  the  articulations,  and  are  fixed  by 
ordinary  mechanical  expedients,  such  as  a  ratchet  wheel,  rack 
and  pinion,  or  best  by  a  perpetual  screw.      (Figs.  16,  17,  18.) 

Of  mechanical  treatment  without  division  of  the  tendon, 
little  need  be  said.  It  is  often  efficient  in  infancy,  and  in 
certain  cases  of  spasmodic  or  slight  deviation.  But  in  a 
common  case  of  chronic  deformity  two  elements  oppose  the  re- 
turn of  the  parts  to  a  normal  condition,  the  distortion  of  the 
bone,  and  the  tension  of  the  unyielding  fibrous  tissue  which 
approximates  its  extremities.  In  severing  these  tense  fibres, 
we  remove  one  of  the  chief  impediments  to  the  restoration  of 

1  These  results  have  been  since  generalized  by  further  observations 
upon  hemorrhage  in  the  human  subject.  Amussat,  Communication  h 
TAcademie  des  Sciences,  October  28,  1844. 


62  ORTHOPEDIC  SURGERY. 

the  part,  as  becomes  evident  from  the  sudden  separation  of 
their  divided  extremities.  It  has  been  abmidantly  proved  that, 
under  proper  restrictions,  the  operation  is  a  safe  one,  and 
that,  while  the  duration  of  treatment  is  abridged,  there  is 
less  chance  of  a  return  of  the  deformity  than  when  unaided 
mechanical  treatment  is  adopted. 


CLUB-FOOT. 

Certain  rare  cases  of  this  distortion  result  from  idiopathic 
malformation,  or  other  lesion  of  the  bony  tissues ;  but  by  far 
the  most  numerous  class  is  due  to  muscular  agency. 

Club-foot  has  been  defined  to  be  the  result  "  of  inequality 
in  the  antagonizing  muscular  forces,  and  of  the  permanent 
retraction  of  certain  muscles."  ^ 

CAUSES. 

Its  causes  may  be  considered  under  two  heads,  congenital  and 
consecutive,  with  reference  to  the  period  of  their  influence. 

Congenital.  —  Among  the  probable  influences  supposed  to 
act  during  the  foetal  state  are  the  following  :  — 

An  intrinsic  muscular  contraction,  due  to  the  agency  of  the 
cerebro-spinal  system.  As  the  most  frequent  cause  of  club- 
foot, this  is  by  far  the  most  important  to  the  surgeon.  It 
occasions  a  large  majority  of  the  cases  with  which  he  is  called 
upon  to  deal. 

The  mechanical  pressure  of  the  uterine  fibres,  or  the  bad 
position  of  the  child  in  utero. 

The  first  of  these  two  varieties  has  been  investigated  by 
Guerin,  who  considers  convulsive  muscular  contraction  as 
an  essential  cause  of  the  congenital  form  of  distortion.  His 
1  Traite  Pratique  du  Pied-bot,  par  Vincent  Duval,  Paris,  1843. 


CLUB-FOOT.  63 

theory  is  founded  upon  dissections  of  foetal  monstrosities  and 
deformities,  where  lesion  of  the  nervous  centre  or  of  its  ram- 
ifications was  evident,  and  upon  the  fact  that  convulsive  action 
often  accompanies  strabismus  and  other  deformity  in  various 
parts  of  the  system. 

In  confirmation  of  this  position  he  offers,  with  other  evi- 
dence, the  following  remarkable  observation.  Twin  infants 
were  affected  with  double  congenital  club-feet,  which  at  the 
end  of  six  months  had  assumed  a  natural  contour,  under 
treatment.  At  this  time  one  of  the  infants  was  seized  with 
convulsions,  accompanied  with  a  return  of  the  club-feet,  which 
were  treated  anew  with  success.  At  the  end  of  a  year  fresh 
convulsions  occurred,  and  the  distortion  was  again  reproduced 
in  one  of  the  feet,  though  in  a  less  degree.^ 

An  unequal  pressure  of  the  uterus  has  been  assigned  as  a 
cause  of  foetal  distortion ;  but  this  explanation  admits  of 
doubt.  The  presence  of  the  water  of  the  amnios  would  tend 
to  counteract  such  pressure,  and  upon  this  ground  Breschet 
rejects  the  theory,  while  Guerin,  on  the  other  hand,  main- 
tains tliat  a  certain  lateral,  but  uniform,  flattening  of  the  foot 
may  result  from  this  cause.  Duval  offers  a  number  of  obser- 
vations tending  to  show  that  certain  positions  of  the  child 
during  uterine  life  may  induce  deformity.  In  these  instances 
the  club-foot  was  accompanied  by  distortions  which  were 
evidently  exaggerations  of  the  natural  position ;  such  as  a 
permanent  folding  of  the  arms,  the  thighs  being  flexed  upon 
the  pelvis.  They  seem  rather  to  indicate  a  general  tendency 
to  muscular  contraction  than  a  distinct  cause  of  the  develop- 
ment of  club-foot. 

Guerin  discards  the  doctrine  of  an  arrest  of  development, 
advanced  by  Breschet,  as  an  original  cause  of  distortion,  but 
admits  the  influence  of  this  principle  as  a  consequence  and 
aid  of  muscular  retraction. 

^  Etiologie  Generale  des  Pieds-bots  Congenitaux,  1843. 


64  ORTHOPEDIC   SURGERY. 

Consecutive.  — These  sources  of  distortion  are  more  readily 
appreciated.  Among  them  are  wounds  of  the  leg  or  plantar 
surface,  blows,  and  sprains.  That  variety  which  results  from 
wounds,  or  from  disease  of  the  bones,  generally  bears  marks 
of  the  lesion  which  has  provoked  the  deformity  ;  and  cica- 
trices and  contractions  of  the  integuments  supply  the  place 
of  the  distinctive  marks  of  retraction. 

It  is  generally  allowed  that  the  paralysis  of  certain  muscles 
may  produce  distortion,  by  permitting  the  unopposed  contrac- 
tion of  the  antagonizing  muscular  forces.  The  subsequent 
transformation  of  these  muscles  then  permanently  confines 
the  limb  in  its  new  position.  The  majority  of  operators  ad- 
vocate tenotomy  in  such  cases,  if  the  distortion  materially 
interferes  with  the  convenience  or  comfort  of  the  patient. 
The  deviation  once  corrected,  the  traction  of  the  healthy 
muscles  may  be  counteracted,  and  the  normal  position  main- 
tained by  springs  or  other  mechanical  contrivances.  In  this 
way  the  condition  of  the  patient  is  often  very  considerably 
improved. 

Both  in  the  congenital  form  and  in  chronic  cases  which 
result  from  spasmodic  action,  occurring  at  a  period  subse- 
quent to  birth,  we  meet  with  the  conditions  of  retraction 
before  described.  The  muscular  fibre  has  given  place  to  a 
more  or  less  fibrous  tissue.  It  has  become  pale  and  atro- 
phied ;  its  development  has  been  arrested,  and  the  points  of 
its  insertion  are  approximated.  Beneath  the  integuments  are 
found  a  series  of  tense,  salient  cords  corresponding  in  position 
with  the  tendons,  and  especially  evident  when  an  effort  is 
made  to  restore  the  foot  to  a  normal  position. 

VAEIETIES. 

Most  authors  recognize  three  varieties  of  club-foot ;  viz. 
Uquhms,  Varus,  and  Valgus. 

Equinus.  —  When  the  heel  is  drawn  towards  the  calf,  and 


CLUB-FOOT.  65 

the  patient  walks  upon  the  toes  or  metatarsal  extremities, 
like  the  horse,  which  gives  a  name  to  the  distortion. 

Varus.  —  When  the  plantar  surface  is  turned  inward,  and 
the  limb  rests  upon  the  outer  edge  of  the  foot. 

Valgus.  —  When  the  sole  is  directed  outward. 

To  these  are  added  a  rare  variety  called  Talus.  Here  the 
toes  are  drawn  upward,  upon  the  front  of  the  leg,  while  the 
heel  alone  remains  upon  the  floor.  It  is  directly  opposed  to 
^quinus. 

Modern  writers  have  proposed  other  divisions. 

Duval  proposes  the  general  term  strephopodie  (o-rpec^eu, 
TToi)?)  for  deviation  of  the  foot,  and  varies  its  application  by 
the  insertion  of  the  prefixes  evSov,  e^co,  vtto,  avco,  Kdrco,  thus: 
streph-endopodie,  -exopodie,  -hypopodie,  -anopodie,  -ocato- 
podie,  for  deviation  inward,  outward,  under,  upward,  and 
downward. 

The  division  of  Bonnet  is  more  worthy  of  attention.  He 
divides  club-foot  into  two  classes  :  ^  — 

Those  forms  produced  by  the  retraction  of  muscles  supplied 
by  the  external  popliteal  nerve. 

Those  produced  by  the  retraction  of  muscles  to  which  the 
internal  popliteal  nerve  is  distributed.  Thus  the  internal 
popliteal  club-foot  includes  the  varieties  Equinus  and  Varus  ; 
while  the  external,  much  less  frequent,  consists  of  the  dif- 
ferent degrees  of  Valgus  and  Talus. 

The  amount  of  distortion  is  marked  by  degrees.  Thus  Dief- 
fenbach  divides  each  of  the  three  ordinary  varieties  into  five 
degrees ;  Phillips  and  Guerin  each  into  three.  Bonnet  sub- 
divides his  two  varieties  each  into  five  degrees. 

I  adopt  the  most  familiar  classification,  and  shall  describe 
three  degrees  of  each  form  of  the  affection. 

1  Sections  Tendineuses,  1841,  p.  432. 
5 


66  ORTHOPEDIC   SURGERY. 

EQUINUS. 

The  first  degree  of  equinus  consists  of  a  direct  elevation 
of  the  heel  from  the  floor,  due  to  the  action  of  the  gastrocne- 
mius. In  the  second,  this  action  is  exaggerated,  and  often 
complicated  by  that  of  other  muscles.  In  the  third,  the  toes 
are  bent  backwards  under  the  foot,  and  the  bony  framework 
is  more  or  less  distorted. 

First  Degree.  —  The  subject  walks  upon  the  extremity  of 
the  aifected  foot,  of  which  the  toes  are  more  or  less  extended 
towards  a  right  angle.  The  calcaneum  is  carried  upward, 
and  the  astragalus  slightly  dislocated  forward.  The  retracted 
muscles  are  those  attached  to  the  tendo  Achillis,  and  occa- 
sionally the  extensor  of  the  great  toe.  The  foot  is  slightly 
arched,  and  shorter  than  its  fellow.  It  presents  upon  its 
plantar  surface  two  callosities,  corresponding  respectively  to 
the  heel  and  ball  of  the  foot,  the  latter  being  well  developed. 
The  toes  are  elevated,  partly  by  the  weight  of  the  body,  and 
partly  by  the  contraction  of  their  tendons. 

Second  Degree.  —  The  mode  of  walking  is  an  exaggeration 
of  the  last ;  the  foot  often  inclining  to  one  or  the  other  side 
when  the  muscular  tension  is  unequal.  The  skeleton  presents 
a  similar  position  of  the  calcaneum  and  astragalus,  the  former 
of  which  sometimes  touches  the  tibia,  while  the  extension  of 
the  toes  throws  the  weight  of  the  body  upon  the  articulating 
extremities  of  the  metatarsals. 

Besides  the  retracted  muscles  of  the  calf,  the  extensors 
and  in  some  cases  the  flexors  of  the  toes  begin  to  appear 
beneath  the  integuments.  The  foot  is  shorter  and  broader, 
the  heel  and  toe  being  drawn  together,  as  Guerin  supposes,  by 
the  retracted  fibres  of  both  surfaces.  Hence  also  its  arched 
form.  The  great  toe  is  occasionally  raised  by  its  own  re- 
tracted tendon,  while  the  other  toes  are  sometimes  flexed 
upon  themselves  in  their  position  of  extension.     The  skin  of 


CLUB-FOOT.  67 

the  plantar  surface  is  wrinkled,  and  presents  a  rough  callus 
at  the  metatarsal  extremities.  That  of  the  heel,  if  it  no  longer 
touches  the  ground,  becomes  smooth  and  delicate. 

Third  Degree.  —  As  the  contraction  increases,  the  extrem- 
ity of  the  foot  gradually  passes  beyond  the  perpendicular. 
The  toes  are  directed  backward,  until  the  dorsal  surface  is 
beneath  and  plays  the  part  of  the  sole.  At  this  degree  it  is 
rarely  uncomplicated  with  one  of  the  other  varieties.  The 
bones  yield  to  the  forcible  retraction  of  the  muscles  and 
to  the  superincumbent  weight.  The  metatarsals  are  curved 
backwards  and  slightly  separated  from  the  cuneiform  bones. 
The  ligamentous  articulations  of  the  tarsus  become  lax,  and 
the  astragalus  is  almost  entirely  dislocated. 

The  gastrocnemius,  the  flexors  and  extensors  of  the  toes, 
and  the  plantar  aponeurosis,  are  concerned  in  this  degree  of 
equinus.  Lateral  complications  involve  other  muscles.  The 
foot  has  become  greatly  distorted.  The  skin  of  the  sole  is 
thin,  while  that  of  the  inverted  upper  surface  has  become 
hard  and  rugous.  Flexion  and  extension  are  precluded,  and 
the  arched  instep  exhibits  in  its  cavity  the  salient  and  re- 
tracted fibres.  The  toes  are  often  interlaced,  the  calf  much 
reduced  in  size,  and  the  knee  somewhat  flexed. 

VARUS. 

The  turning  inward  of  the  foot  is  characteristic  of  this 
complex  form. 

In  the  first  degree  the  inner  edge  of  the  foot  is  raised  from 
the  ground.  In  the  second,  the  patient  walks  upon  the  outer 
edge,  while  in  the  third  the  sole  is  directed  upward,  and  the 
dorsum  fulfils  the  functions  of  a  plantar  surface. 

In  simple  varus  the  foot  is  raised  upon  its  external  edge, 
while  the  sole,  looking  inward,  is  directed  forward  and  back- 
ward.    It  is  rare.     Guerin  observed  but  seven  cases  in  four 


68  ORTHOPEDIC  SURGERY. 

hundred  club-feet ;  or  less  than  two  in  one  hundred.^  It  is 
more  frequently  complicated  with  equinus ;  which  has  led  the 
same  author  to  make  the  divisions  of  varus,  varus  equinus, 
and  equinus  varus,  as  the  one  or  the  other  gradation  predom- 
inates ;  each  of  the  last  two  being  subdivided  into  three  de- 
grees. The  inward  inclination  of  the  foot  is  sometimes  due 
to  the  unaided  action  of  the  gastrocnemius,  but  more  com- 
monly results  from  the  traction  of  other  muscles. 

The  distortion  of  the  skeleton  may  be  resolved  into  two 
elements ;  adduction  and  extension. 

Adduction.  —  The  astragalus  forms  a  centre  for  the  move- 
ments of  the  calcaneum  and  scaphoid  bones.  The  cuboid 
moves  upon  the  calcaneum,  the  cuneiform  upon  the  scaphoid, 
while  the  toes  follow  the  cuneiform  in  their  progress  inward. 
The  calcaneum  presents  its  inferior  face  to  the  opposite  foot, 
but  its  attachments  to  the  astragalus  undergo  little  modifica- 
tion. The  cuboid  is  carried  inward  with  the  scaphoid,  and 
exposes  a  small  portion  of  the  surface  by  which  it  is  artic- 
ulated with  the  calcaneum.  The  scaphoid  undergoes  a  more 
considerable  displacement.  It  is  even  partially  dislocated. 
Passing  inside  the  head  of  the  astragalus,  and  descending 
from  its  upper  part,  its  position  is  oblique.  The  head  of  the 
astragalus,  at  its  external  and  upper  part,  is  salient  beneath 
the  integuments,  while  a  new  articulation  is  formed  upon 
its  internal  surface. 

Extension.  —  The  trochlea  glides  through  its  socket,  and  is 
exposed  in  front  of  the  tibia  and  fibula.  A  number  of  new 
articulations  result  from  this  forced  extension.  The  sca- 
phoid, at  its  superior  internal  part,  comes  in  contact  with 
the  internal  malleolus.  Behind,  the  tibia,  and  finally  the 
fibula,  are  articulated  to  the  calcaneum.  The  displaced  ar- 
ticular surfaces  become  gradually  ossified.     The  head  of  the 

1  Memoire  sur  les  Difformit^s  du  Corps  Humain,  Paris,  1843,  p.  320. 


CLUB-FOOT.  69 

astragalus  is  depressed  internally,  and  the  anterior  facet  of 
the  calcaneum,  absorbed  upon  its  internal  surface,  becomes 
oblique. 

The  walk,  in  varus,  is  difficult.  In  the  exaggerated  form, 
the  patient  often  requires  a  crutch  or  cane.  The  skin  of  the 
dorsal  surface,  before  it  acquires  a  power  of  resistance,  often 
takes  on  inflammatory  action  at  its  point  of  contact  with  the 
ground.  The  knees  are  inclined  inward,  and  the  affected  foot 
swings  over  its  fellow,  or  describes  curves  to  avoid  it.  The 
muscular  action  is  complicated.  The  elevation  of  the  heel  is 
due  to  the  muscles  of  the  calf.  The  chief  agents  of  adduction 
are  the  tibiales  posticus  and  anticus.  As  the  foot  deviates 
inward,  the  tendo  Achillis  begins  to  act  in  the  chord  of  the 
arc  described  by  the  leg  and  heel,  and  exerts  an  important 
influence  in  adduction.  The  flexor  of  the  great  toe  now  be- 
gins to  draw,  and  the  foot,  yielding  to  the  combined  action 
of  this  muscle  and  the  flexors  of  the  sole,  curves  upon  itself. 
In  other  cases  the  common  flexor  of  the  toes  and  the  adductor 
of  the  great  toe  are  retracted,  and  both  the  flexors  and  exten- 
sors of  the  foot,  acting  as  adductors  from  the  change  in  the 
direction  of  their  insertions,  promote  the  distortion.  The 
curve  of  the  foot  is  aided,  in  this  position,  by  the  retraction 
of  its  dorsal  muscles  and  the  plantar  aponeurosis,  while  the 
tension  of  the  long  peroneal  compresses  it  laterally. 

In  its  later  stages  this  variety  yields  with  difficulty  to  sur- 
gical treatment.  The  relations  of  the  bones  are  much  altered, 
and  the  shape  of  the  foot  is  sometimes  little  modified  after 
section  of  the  tendons.  In  cases  of  extreme  distortion,  the 
foot  resembles  a  huge  fist.  The  toes  are  flexed  and  inter- 
laced, and  the  dorsal  surface,  if  in  contact  with  the  ground, 
is  occupied  by  a  rough  callus.  Large  and  remarkable  bursa3 
are  sometimes  found  under  the  cuboid  bone  when  the  de- 
formity has  existed  for  a  series  of  years. ^     The  now  delicate 

^  Listen,  On  Diseases  of  the  Bursae,  Lancet,  October  21,  1843. 


70  ORTHOPEDIC  SURGERY. 

skin  of  the  sole  is  much  wrinkled ;  the  leg  is  more  or  less 
atrophied,  and  often  permanently  flexed  upon  the  thigh. 

VALGUS. 

This  form,  in  which  the  sole  is  turned  outward,  is  the  oppo- 
site of  varus. 

The  first  degree  is  what  has  been  called  flat  foot,  and  is 
characterized  by  obliteration  of  the  arch,  with  occasional  re- 
traction of  the  extensors  of  the  toes. 

In  the  second  degree,  the  sole  is  raised  from  the  ground, 
and  the  weight  of  the  body  is  thrown  upon  the  inside  of  the 
foot. 

The  third  presents  different  characteristics,  due  to  the  re- 
traction of  different  muscles.  The  relations  of  the  bones  of 
the  tarsus  and  metatarsus  are  altered. 

First  Degree.  —  The  skeleton  is  little  modified.  The  liga- 
ments and  muscles  which  unite  the  extremities  of  the  arched 
sole  are  relaxed,  while,  in  some  cases,  the  retraction  of  the 
extensors  aid  in  elevating  its  anterior  extremity.  The  foot  is 
closely  applied  to  the  ground,  and  rotated  outward. 

Second  Degree.  —  The  astragalus  is  partially  luxated  back- 
ward, and  the  cuboid  and  scaphoid  displaced  externally.  The 
peroneals  and  extensors  of  the  toes  raise  the  outer  border  of 
the  foot,  the  anterior  part  of  which  is  carried  upward  and 
outward,  the  toes  being  elevated  by  their  extensors. 

Third  Degree.  —  The  scaphoid  sometimes  abandons  the 
internal  surface  of  the  head  of  the  astragalus,  which  then 
becomes  inarticular.  The  bones  of  the  tarsus  separate  one 
from  another,  yielding  to  the  retracted  muscles.  The  pero- 
neals, the  extensors  of  the  toes,  the  abductor  of  the  little  toe, 
and  the  accessory  muscles  are  retracted.  The  metatarsals 
sometimes  leave  the  anterior  articulating  facets  of  the  cunei- 
form, to  take  a  position  upon  their  superior  surface,  at  an 
acute  angle  with  the  leg. 


CLUB-FOOT.  71 

If  the  tendo  Achillis  be  also  contracted,  the  patient  walks 
upon  the  central  portion  of  the  sole,  with  the  heel  and  toes 
raised.  In  this  exaggerated  form,  a  small  surface  is  applied 
to  the  ground,  and  the  skin  not  unfrequently  becomes  inflamed 
and  ulcerated.  The  form  of  the  foot  varies  with  the  perma- 
nent forces  applied  to  it. 

It  is  difficult  to  imagine  that  the  unaided  muscles  of  the 
external  surface  of  the  leg  should  overpower  the  resistance 
exerted  by  those  of  the  inner  side.  Guerin  affirms  that  a 
pronounced  valgus  is  an  indication  of  a  more  or  less  com- 
plete paralysis  of  the  gastrocnemius,  tibiales,  and  flexors  of 
the  toes.  Mr.  Little  suggests  that  another  reason  for  the 
greater  frequency  of  varus  is  the  fact  that  the  flexors  and 
adductors  are  earlier  developed  in  the  foetal  state  than  the 
extensors  and  abductorSc 

TALUS. 

Talus  is  a  name  applied  to  a  rare  deformity  nearly  allied 
to  the  last,  and  directly  opposed  to  equinus.  The  foot  is  in 
forced  flexion,  and  the  trochlea  exposed  posteriorly.  The 
retracted  muscles  are  those  of  the  anterior  part  of  the  leg 
and  dorsum  of  the  foot.  According  to  Guerin,  this  affection 
also  implies  a  paralysis  of  the  antagonizing  muscles.  The 
toes  are  in  contact  with  the  front  of  the  leg,  and  the  weight 
of  the  body  is  thrown  upon  the  heel. 

In  all  these  forms  the  original  distortion  is  due  rather  to 
the  muscles  than  to  the  aponeuroses  and  ligaments,  which 
undergo  subsequent  retraction. 

TEEATMENT   WITHOUT   SECTION   OP   TENDONS. 

Before  the  introduction  of  the  subcutaneous  operation  it  was 
common  to  treat  club-foot  by  the  unaided  force  of  machines. 
Although  this  principle  is  still  maintained  by  certain  ortho- 
pedists, it  cannot  be  deduced  from  a  scientific  consideration 


72  ORTHOPEDIC  SURGERY. 

of  the  subject.  It  is  now  a  well  established  fact  that  in  cer- 
tain cases  of  distortion  the  tissue  of  the  shortened  mus- 
cles undergoes  a  fibrous  transformation;  and  it  is  highly 
probable,  if  not  equally  certain,  that  this  transformation  is  in 
proportion  to  the  degree  of  tension  to  which  the  muscular 
substance  has  been  subjected.  In  an  old  case  of  varus,  for 
example,  the  leg  and  foot  form  a  sort  of  bent  bow,  of  which 
the  extremities  are  united  by  a  cord  of  fibrous  tissue,  which 
at  once  becomes  tense  when  an  attempt  to  straighten  the 
limb  is  made.  It  seems  obvious  that  the  first  step  towards 
straightening  the  bow  is  to  sever  the  string  which  aids  in 
keeping  it  flexed ;  and  this  treatment  is  in  fact  indicated, 
unless  it  can  be  shown  either  that  the  operation  is  attended 
with  danger  or  inconvenience  to  the  patient,  or  that  unaided 
mechanical  treatment  is  equally  efiicacious. 

Now  it  is  well  known  that  the  subcutaneous  division  of  a 
tendon,  when  properly  performed,  is  attended  with  trifling 
pain,  and  that  there  is  little  or  no  chance  of  subsequent 
inflammatory  accidents.  On  the  other  hand,  very  severe 
pain  often  accompanies  the  attempt  to  elongate  a  retracted 
tendon  by  simple  extension.  And  while  few  at  the  present 
day  will  dispute  that  the  time  occupied  by  this  process  is 
much  longer,  the  deformity  is  liable  to  reappear  at  a  sub- 
sequent period. 

It  is  not  here  implied  that  all  cases  of  distortion  de- 
mand an  indiscriminate  division  of  tendons.  On  the  con- 
trary, there  are  certain  cases  of  recent  deformity,  and  of 
disease  originating  in  the  joint  and  not  in  the  muscles, 
where  the  tenotome  may  not  be  required.  In  such  cases  the 
surgeon  should  be  guided  by  a  knowledge  of  the  original 
lesion  and  its  effects.  If,  however,  a  single  rule  were  re- 
quired, applicable  in  a  large  majority  of  cases,  it  should  be 
as  follows :  When  in  distortion  of  long  standing,  with  a  cer- 
tain degree  of  motion  still  remaining  in  the  joint,   a  tendon 


CLUB-FOOT.  73 

evidently  hinders  the  limb  from  assuming  a  normal  position,  it 
should  he  divided. 

Upon  this  subject  Bonnet  (de  Lyon)  thus  speaks :  "  Among 
children  it  is  often  possible  to  cure  club-feet  by  machines 
alone,  by  friction,  etc.  ;  but  as  in  easy  cases  the  section  of 
the  tendons  insures  success,  abridges  the  treatment,  and 
avoids  pain,  and  as  it  is  besides  perfectly  innocent,  I  believe 
that  recourse  should  always  be  had  to  it  except  in  infants 
who  are  to  be  treated  during  the  first  months  which  follow 
their  birth.  It  is  then  so  easy  to  bring  the  foot  into  a  nor- 
mal position,  that  friction  and  machines,  which  at  a  more 
advanced  period  of  life  are  only  accessories  of  treatment, 
become  its  principal  feature,  and  are  adequate  alone  to  pro- 
duce the  desired  effect. "  ^ 

The  same  distinction  is  made  by  Guerin  between  the  treat- 
ment of  the  conditions  of  contraction  and  retraction. 

"  Simple  contraction  permits  us  to  hope  for  the  immediate 
elongation  of  the  muscles  by  means  proper  to  effect  it,  — 
extension,  kneading  {massage),  frictions,  etc., — while  veri- 
table retraction,  or  shortening  with  fibrous  degeneration, 
implies  either  the  impossibility  of  a  return  of  the  muscles 
to  a  normal  length,  or  a  sufficient  mechanical  elongation, 
and  demands  in  consequence  the  aid  of  a  cutting  instru- 
ment. Thus,  recent  deformities  by  contraction — torticollis, 
flexion  of  the  limbs,  etc. —  may  be  often  successfully  treated 
by  mechanical  and  medical  agents,  while  old  deformities  by 
retraction  demand  peremptorily  surgical  appliances.  "^ 

For  simple  mechanical  treatment,  different  methods  have 
been  devised. 

In  the  apparatus  of  Venel  the  action  is  lateral ;  in  varus, 
for  example,  upon  the  external  side  of  the  leg,  and  the  inter- 
nal surfaces  of  the  foot  and  heel. 

1  Traite  des  Sections  Tendineuses,  etc.,  Paris,  1841,  p.  567. 

2  Vues  Generales,  etc.,  Paris,  1840,  p.  73. 


74  ORTHOPEDIC   SURGERY. 

Delpech  employed  two  machines ;  the  first,  to  bring  the  foot 
straight;  the  second,  to  attain  the  horizontal  position. 

Dieffenbach  and  Guerin  have  employed  plaster  for  the  same 
purpose.  The  foot,  placed  in  a  box,  is  brought  as  far  as  pos- 
sible into  a  normal  position,  and  covered  with  liquid  plaster, 
which  is  allowed  to  set.  This  is  subsequently  renewed  at  in- 
tervals of  two  or  three  weeks.  A  small  hole  broken  in  the 
mass  exhibits  the  condition  of  the  tissues  during  treatment. 
Guerin  especially  recommends  this  method,  when  the  deli- 
cate and  irritable  skin  of  young  subjects  refuses  to  submit 
to  the  pressure  of  bandages.  The  force  is  equably  distrib- 
uted, while  the  cuticle  is  softened  by  the  retained  trans- 
piration. 

Mechanical  aid  is  occasionally  useful  for  the  purpose  of 
rendering  a  tendon  tense  and  salient  before  section.  But 
apparatus  requires  continued  care  and  frequent  application, 
especially  in  infants,  where  the  tissues,  compressed  by  the 
straps,  diminish  in  volume,  and  the  foot  becomes  loose. 

SECTION    OF   TENDONS   IN    CLUB-FOOT. 

Different  varieties  of  the  deformity  demand  the  section  of 
different  fibrous  fasciculi :  — 

For  the  elevation  of  the  heel,  the  tendo  Achillis.  For  the 
foot  raised  upon  its  outer  edge,  the  tibialis  anticus ;  turned 
upon  its  internal  edge,  the  peroneus  tertius,  and  all  or  part 
of  the  extensors  of  the  toes.  For  adduction,  the  tibialis 
posticus;  for  abduction,  the  peronei  longus  and  brevis. 

For  the  curvature  of  its  internal  border,  the  adductor  of 
the  great  toe.  For  the  permanent  flexion  and  extension  of 
the  toes,  their  corresponding  muscles,  both  long  and  short. 
And  finally,  when  accessory  to  the  distortion,  the  plantar 
aponeurosis,  and  any  of  the  tendinous  and  muscular  fibres 
of  the  foot  and  leg. 

In  these  different  varieties  of  distortion,  M.  Guerin  has 


CLUB-FOOT.  75 

commonly  divided  the  tendons  as  follows.  For  equinus, 
the  tendo  Achillis,  and  sometimes  the  flexor  proprius  of 
the  great  toe.  For  pure  varus,  the  tendo  Achillis  ajtid 
tibialis  posticus.  For  varus  equinus,  the  tibiales  ajiticus 
and  posticus,  the  tendo  Achillis,  the  extensor  proprius 
and  adductor  of  the  great  toe,  and  sometimes  the  peroneus 
longus.  For  valgus,  the  peroneus  tertius  and  the  peronei 
longus  and  brevis.  For  talus,  the  tibialis  anticus,  the  pero- 
neus tertius,  and  the  common  extensor  of  the  toes.  And 
finally,  the  plantar  aponeurosis,  together  with  other  muscles 
in  less  common  instances. 

Before  the  volume  of  Bonnet  (de  Lyon),  published  in  1841, 
I  believe  no  w^riter  had  minutely  described  the  manner  of 
dividing  the  different  tendons  of  the  leg.  Operations  upon 
the  tendo  Achillis  and  tibialis  anticus  were  already  the 
subject  of  various  memoirs;  but  the  tibialis  posticus  and 
the  peroneals  of  the  ankle  had  not  at  that  time  been  divided 
upon  the  living  subject,  although  their  position  was  indicated 
by  Velpeau,  with  a  view  to  their  section.  Duval,  in  his 
second  edition,  published  in  1843,  gives  certain  details  upon 
this  point. 

The  manual  of  the  subcutaneous  operation  has  been  already 
indicated  in  general  terms.  The  tendon  is  made  salient  if 
possible.  A  fold  of  skin  being  pinched  up  at  one  end  be- 
tween the  thumb  and  finger  of  the  operator's  left  hand,  the 
other  end  is  confided  to  an  aid,  and  the  tenotome  introduced 
by  a  simple  puncture  at  its  base.  The  fold  is  then  released 
so  that  the  puncture  may  recede  to  a  distance  from  the  point 
of  section,  and  the  tendon  is  divided  by  a  sawing  motion. 

Tendo  Achillis.  —  The  patient  commonly  lies  upon  his 
belly,  though  Dieffenbach  prefers  a  kneeling  position. 

The  place  of  section  is  of  importance.  Duval  and  some 
other  writers  merely  indicate  a  point  an  inch  or  two  above 
the  calcaneum.     This  distance  must  evidently  vary  with  the 


76  ORTHOPEDIC  SURGERY. 

dimensions  of  the  limb,  and  certain  other  considerations, 
but  as  a  general  rule  the  most  salient  point  should  be  pre- 
ferred. While  the  muscular  fibres  are  to  be  avoided  above, 
the  vs^ant  of  vitality  in  the  tissues  forbids  a  section  too  near 
the  bone  of  the  heel. 

When  the  tendon  is  contracted  it  sometimes  approaches 
the  posterior  tibial  artery  and  veins.  These  are  avoided 
by  receding  from  the  heel. 

Scoutetten  describes  a  bursa  mucosa  near  the  calcaneum, 
the  puncture  of  which  might  liberate  the  synovial  secre- 
tion in  sufficient  quantity  to  interfere  with  a  reunion  of  the 
tendon. 

Authorities  are  divided  upon  the  direction  of  the  section. 
Stromeyer,  Scoutetten,  and  Duval  cut  from  the  bone  toward 
the  surface,  while  Bouvier,  Dieffenbach,  Guerin,  and  many 
other  surgeons,  enter  the  knife  beneath  the  integuments, 
and  incise  toward  the  bone.  It  is,  in  general,  a  matter  of 
little  importance  whether  the  section  be  commenced  upon 
the  anterior  or  posterior  surface  of  the  tendon.  When,  how- 
ever, the  tendon  so  nearly  approaches  the  posterior  tibial 
artery,  with  its  accompanying  veins  and  nerve,  that  it  is 
difficult  to  engage  it  alone  upon  the  blade,  it  is  evidently 
better  to  cut  toward  the  bone,  that  the  edge  may  repel  the 
yielding  vessels. 

If  a  pointed  tenotome  be  employed,  it  should  be  hindered 
from  piercing  the  integuments  of  the  opposite  surface.  The 
safest  plan  is  to  employ  a  blunt  tenotome,  a  puncture  being 
first  made  with  a  lancet  or  pointed  knife. 

Most  surgeons  prefer  to  make  this  aperture  upon  the  inside 
of  the  heel,  —  a  preference  for  which  no  strong  reason  is 
offered.  The  integuments  are  somewhat  more  lax  and  the 
tendon  is  occasionally  more  voluminous  upon  that  side, 
but  the  slender  tendon  of  the  plantaris  is  there  almost 
directly  beneath  the  instrument. 


CLUB-FOOT.  77 

A  fold  of  the  integument  being  pinched  up,  and  the  teno- 
tome being  introduced  at  its  base,  the  foot  is  extended  by 
the  operator,  and  the  tendon,  when  tense,  severed  by  a 
sawing  movement  of  the  blade.  The  moment  of  section 
is  accompanied  with  a  noise,  and  with  a  separation  of  the 
extremities  in  most  cases,  although  the  bones  are  sometimes 
so  distorted,  or  other  tendons  so  retracted,  that  this  separa- 
tion is  inconsiderable.  The  air  being  carefully  excluded, 
and  the  blood  expelled,  as  far  as  practicable,  the  wound  is 
closed  with  adhesive  plaster. 

The  division  of  other  tendons  may  precede  or  follow  that 
of  the  tendo  Achillis.  Velpeau  divides,  in  the  same  opera- 
tion, all  the  retracted  tendons.  Phillips,  Duval,  and  others 
seek  first  to  reduce  the  complicated  varieties  of  the  deformity 
to  the  simple  form  of  equinus,  and  then  the  tendo  Achillis 
is  subsequently  divided.  Both  methods  recommend  them- 
selves by  their  results,  but  the  latter  is  more  generally 
adopted. 

Tibialis  Anticus.  —  This  muscle  is  best  divided  at  its  most 
salient  point,  a  few  lines  below  the  annular  ligament.  Be- 
neath is  the  articulation  of  the  astragalus  with  the  tibia 
and  fibula,  which  might  be  endangered  by  too  deep  a  sec- 
tion. M.  Bonnet  asserts  that  the  division  of  the  tendo 
Achillis  often  relaxes  the  tibialis  anticus,  and  obviates  the 
necessity  of  its  section. 

Tibialis  Posticus.  —  Certain  cases  of  exaggerated  distor- 
tion have  been  supposed  to  demand  the  section  of  this  tendon, 
though  the  operation  is  comparatively  rare,  and  of  difficult 
execution.  Behind  the  tibia  it  is  enclosed  in  a  sheath,  in 
the  neighborhood  of  an  artery  of  considerable  size.  Some 
anatomical  knowledge  is  required  to  reach  its  position  below 
the  ankle,  since  it  is  rarely  salient,  and  its  section  is  unat- 
tended with  perceptible  separation  of  its  extremities.  In 
cases  of  complicated  equinus,    when   the   scaphoid  is  at  a 


78  ORTHOPEDIC   SURGERY. 

distance  from  the  external  malleolus,  the  following  method 
of  M.  Bonnet  may  be  adopted.  The  eminence  of  the  head 
of  the  scaphoid  being  found,  the  tenotome  is  entered  at  a 
quarter  of  an  inch  above,  and  a  little  in  front  of  it,  and 
advanced  till  it  meets  the  astragalus.  The  instrument  is 
then  slid  along  against  the  bone  until  its  extremity  arrives 
at  a  point  four  or  five  lines  beneath  the  prominence  of  the 
scaphoid.  If  the  edge  of  the  tenotome  be  now  raised  until 
it  reaches  the  skin,  the  tendon  is  with  certainty  divided. 
This  method  is  inapplicable  in  the  more  marked  degrees  of 
varus. 

The  Extensors  of  the  Toes  should  be  severed  at  their  most 
prominent  point,  commonly  at  the  articulation  of  the  meta- 
tarsals withthe  phalanges. 

Peronei  Longus  and  Brevis.  —  These  tendons  are  enclosed 
in  a  fibrous  sheath,  above  or  below  which  they  may  be 
divided.  Above,  they  are  occasionally  quite  prominent. 
The  position  to  be  chosen  below  is  about  half  an  inch  in 
front  of  the  ankle,  and  as  was  indicated  for  the  tibialis 
posticus.  The  surest  method  consists  in  introducing  the 
pointed  tenotome  behind  the  tendon,  and  cutting  from  within 
outward.  This  position  endangers  the  articulation  less,  and 
allows  the  instrument  to  pass  free  of  a  protuberance  situated 
upon  the  external  side  of  the  calcaneum. 

Flexor  Communis  and  Flexor  Longus  Pollicis.  —  The  depth 
of  these  tendons  renders  their  section  difficult  elsewhere 
than  on  a  line  with  the  first  phalanges  of  the  toes. 

The  blade  is  slid  beneath,  and  advanced  to  the  surface. 
The  short  flexors  may  be  included  in  the  section. 

The  Plantar  Aponeurosis  is  often  retracted,  and  requires 
division.  The  tenotome  should  be  introduced  at  the  inner 
edge  of  the  foot,  where  the  fibres  are  in  strong  relief, 
commonly  at  a  point  near  the  articulation  of  the  first  with 
the  second  range  of  the  tarsus.     The  section  should  not  be 


CLUB-FOOT.  79 

carried  so  deep  as  to  wound  the  articulation.  This  is  per- 
haps the  most  painful  of  these  operations. 

The  narrow  blade  being  carefully  withdrawn  without 
enlarging  the  puncture,  the  blood  and  any  accidental  bubble 
of  air  are  expressed.  The  finger  is  kept  upon  the  wound 
until  a  bit  of  adhesive  plaster  is  made  ready  and  applied, 
so  as  to  seal  the  orifice  hermetically. 

The  foot  may  be  then  enveloped  for  an  hour  or  two  with  a 
wet  compress,  which  relieves  a  local  burning  pain  sometimes 
experienced  by  the  patient. 

A  redi vision  of  this  tendon  is  occasionally  required  during 
the  mechanical  treatment,  and  is  indicated  by  the  resistance 
and  prominence  of  the  tendon.  A  twice  or  thrice  repeated 
section  is  not  uncommon,  nor  is  it  objectionable;  but  the 
tendo  Achillis  has  been  unjustifiably  divided  upwards  of 
twenty  times  upon  the  same  individual. 

The  new  division  should  be  effected  a  short  distance  above 
the  cicatrix  which  occupies  the  position  of  the  previous 
section. 

MECHANICAL  TREATMENT. 

It  has  been  a  question  whether  force  should  be  immediately 
applied  after  the  section  of  tendons,  or  whether  it  should  be 
delayed  to  a  subsequent  period.  Velpeau  gives  preference 
to  immediate  mechanical  treatment.  Duval,  while  he  recom- 
mends the  foot  to  be  at  once  placed  in  a  machine,  to  retain 
any  advantage  that  may  have  been  gained  by  the  section 
alone,  deprecates  immediate  extension.  I  believe  that  many 
of  the  inflammatory  accidents  so  frequently  reported  as  re- 
sults of  tenotomy  are  to  be  attributed  to  a  too  hasty  appli- 
cation of  force.  It  may  be  asserted  that  a  large  majority 
of  European  orthopedic  surgeons  follow  the  example  of 
Stromeyer,  and  wait  for  the  cicatrization  of  the  puncture 
before  applying  extension  to  the  limb.    In  this  country  this 


80  ORTHOPEDIC  SURGERY. 

practice  was  recommended  by  Dr.  Hayward  of  Boston  as 
long  ago  as  1841.* 

At  the  end  of  forty-eight  or  seventy-two  hours,  or  even  a 
much  longer  period,  when  the  integuments  are  united,  and 
the  tendon  has  set  up  a  restorative  process,  force  may  be 
gently  applied. 

The  adjustment  of  a  machine  requires  much  immediate  and 
subsequent  care.  A  gradual  and  long  continued  force  alone 
will  induce  the  foot  to  resume  its  normal  position.  The 
foot  is  unequally  covered  with  tissues,  and  a  slight  pressure, 
even  of  a  strap,  a  lump  of  cotton,  or  a  fold  of  bandage, 
becomes  painful  where  the  bone  projects.  This  is  especially 
true  of  thin  subjects. 

The  pain  is  in  general  dull,  though  sometimes  insupport- 
able. In  equinus  the  great  toe  and  instep  are  more  frequently 
the  seat  of  pain,  while  in  the  treatment  of  varus  it  occupies 
the  external  border  of  the  foot,  is  lancinating,  and  is  exacer- 
bated by  the  warmth  of  the  bed. 

If  the  pressure  be  continued,  the  skin  becomes  red,  hot, 
and  exhibits  a  gangrenous  vesicle,  followed  by  slough  and 
ulceration.  At  other  times  the  foot  is  much  swelled,  while 
the  limb,  especially  in  scrofulous  subjects,  becomes  more  or 
less  oedematous. 

When  the  pain  is  local  and  permanent,  the  apparatus 
should  be  removed,  and  the  skin,  if  red,  soothed  with  emol- 
lient and  narcotic  lotions.  At  the  end  of  a  few  hours  the 
machine  may  be  reapplied,  the  spot  being  well  protected 
with  cotton.  In  case  of  an  eschar,  the  ulcer  should  be 
allowed  to  heal  before  any  attempt  to  continue  mechanical 
treatment  is  made. 

The  first  application  of  a  machine  is  always  ineffectual. 
The  tissues  require  time  to  accustom  and  adapt  themselves 
to  their  new  position.     They  are  impatient  of  force,  or  are 

1  Boston  Medical  and  Surgical  Journal,  1841,  p.  313. 


CLUB-FOOT.  81 

SO  compressed  that  the  foot  becomes  loose  in  the  machine. 
When  it  is  necessary  to  change  the  apparatus,  it  is  impor- 
tant to  maintain  the  foot  in  its  new  position  during  the 
process.  If  allowed  to  escape  from  the  hand  for  a  moment, 
it  tends  to  resume  its  recent  form,  a  movement  accompanied 
with  great  pain.  The  part  should  be  kept  cool.  During 
the  first  ten  or  twelve  days  it  is  well  to  examine  the  apparatus 
once  or  twice  a  day.  It  is  better  also  to  increase  extension 
in  the  morning  rather  than  the  evening,  when  the  consequent 
pain  sometimes  hinders  the  patient  from  sleeping.  A  want 
of  attention  to  these  details  may  involve  the  necessity  of 
suspending  the  treatment  and  the  progress  of  several  days 
is  sometimes  lost  in  a  short  time. 

MACHINES. 

It  remains  to  describe  some  of  the  principal  machines 
employed  in  the  treatment  of  club-foot.  The  principles  and 
aim  of  most  of  them  are  the  same.  They  offer  different 
mechanical  combinations,  which  belong  rather  to  the  mech- 
anician than  the  surgeon.  It  is  this  peculiarity,  together 
with  the  assiduous  care  required  in  the  use  of  apparatus, 
which  has  led  to  the  establishment  of  institutions  devoted 
to  the  treatment  of  deformity,  and  has  created  a  class  of 
specialists  known  as  "orthopedists." 

The  machines  may  be  described  as  consisting  of  a  series 
of  pieces,  each  adapted  to  a  corresponding  detached  portion 
of  the  skeleton,  and  united  by  joints,  the  movements  of 
which  represent  those  of  the  articulations. 

The  apparatus  should  be  capable  of  conforming  itself  to 
the  curve  of  the  distorted  limb,  and  provided  with  screws, 
or  other  mechanical  contrivances,  for  forcibly  restoring  the 
parts  to  a  normal  position.     (Figs.  16,  17,  18.) 

6 


82  ORTHOPEDIC   SURGERY. 

EQUINUS. 

When  the  deviation  is  slight,  it  suffices,  after  section  of 
the  tendons,  to  confine  the  foot  in  a  common  boot,  the  leg  of 
which  is  of  stiff  cowhide,  and  laced  in  front.  The  starched 
bandage  is  also  employed  with  success  for  this  purpose. 

If  the  distortion  is  great,  these  methods  are  insufficient, 
and  it  becomes  necessary  to  employ  a  certain  amount  of 
force.  The  machine  of  Stromeyer,  and  the  boot  of  Scarpa, 
may  be  regarded  as  the  type  of  such  apparatus,  and  have 
undergone  various  modifications. 

The  Machine  of  Stromeyer  (Fig.  14),  employed  by  Dieffen- 
bach,  consists  of  two  bars  of  wood  extending  from  the  ham  to 
the  ankle  on  each  side  of  the  leg,  and  united  by  cross-pieces 
at  top  and  bottom.  A  third  sliding  cross-piece,  capable  of 
being  fixed  by  screws,  serves  as  an  axis  of  flexion  and 
extension  to  a  piece  of  board  which  corresponds  to  the  sole  of 
the  foot.  The  flexion  of  this  wooden  sole  is  efiPected  by  two 
cords,  which,  attached  to  its  upper  corners,  traverse  pulleys 
at  the  upper  part  of  the  parallel  bars,  and  return  to  a  roller 
governed  by  a  ratchet  at  the  lower  extremity.  The  calf  of 
the  leg  rests  upon  a  sheet  of  leather  attached  to  the  parallel 
bars,  and  is  secured  by  straps. 

Scarpa's  Boot  (Fig.  15),  which  has  been  modified  by  Guerin, 
Phillips,  and  others,  presents  a  sort  of  shoe  open  at  top,  and 
united  by  straps.  At  the  ankle  it  is  articulated  with  two 
lateral  uprights  of  metal,  which  are  bound  to  the  leg  at 
intervals  by  wadded  straps.  The  flexion  of  this  joint  is 
governed  by  a  screw  fixed  by  its  extremity  to  the  sole,  and 
passing  obliquely  to  one  of  the  metal  uprights.  The  sole 
itself  is  sometimes  jointed,  and  admits  of  a  lateral  movement, 
which  accommodates  it  to  the  lateral  varieties  of  club-foot. 
It  is  governed  by  a  screw  upon  its  edge.^ 

1  Modifications  of  these  joints  will  be  found  in  the  drawings. 


CLUB-FOOT.  83 

The  machine  of  Stromeyer  is  possessed  of  greater  force 
than  the  boot  of  Scarpa,  while  the  latter  is  more  portable. 
The  boot,  worn  to  advantage  during  the  day,  may  be  replaced 
by  the  machine  of  Stromeyer  at  night. 

VARUS. 

The  treatment  of  varus  is  more  difficult,  the  resistance  of 
the  skeleton  in  the  exaggerated  forms  being  often  great. 

In  young  children  it  sometimes  suffices  to  sever  the  tendo 
Achillis,  and  apply  subsequently  the  starched  bandage.  For 
older  children  the  boot  of  Scarpa  may  be  employed. 
Phillips,  Duval,  and  Little  prefer,  when  the  deviation  is 
great,  to  attack  the  distortion  of  adduction,  and  to  convert 
the  form  of  varus  into  simple  equinus  before  dividing  the 
tendo  Achillis.  If  this  method  be  adopted,  the  result  may 
be  attained  in  the  following  way.  The  leg,  when  the  punc- 
tures are  healed,  should  be  enveloped  in  wadding  which  is 
confined  by  a  bandage  (Fig.  19).  A  long  splint,  mortised  at 
its  extremities,  is  cushioned  and  applied  to  the  external 
surface  of  the  leg,  extending  from  the  knee  to  about  six 
inches  below  the  heel.  The  superior  extremity  is  fixed  to 
the  head  of  the  fibula  by  a  band,  which,  after  passing  through 
the  mortise,  is  continued  around  the  leg  to  the  heel,  and 
starched.  The  splint  being  thus  bound  to  the  leg,  its  lower 
and  projecting  extremity  serves  as  a  point  of  attachment  to 
a  band,  which  is  fixed  by  several  turns  to  the  end  of  the  foot, 
and  serves  to  draw  it  outward.  The  varus  is  thus  gradually 
converted  into  equinus. 

Aji  Ingenious  Method  of  Dieffenhach  (Fig.  20)  applies  to 
certain  cases  of  slight  deviation.  The  middle  of  a  yard  of 
starched  band,  looped  round  the  inside  of  the  heel,  crossed 
on  the  outer  ankle  and  adhering  to  the  calf,  tends  to  draw 
the  heel  outward.  A  similar  loop,  not  starched,  is  allowed 
to  hang  loose  a  few  inches  below  the  inner  ankle  and  sole. 


84  ORTHOPEDIC   SURGERY. 

and  is  firmly  bandaged  to  the  internal  surface  of  the  leg. 
A  long  splint,  terminated  by  a  lateral  notch,  which  is  en- 
gaged in  this  loop,  is  now  bound  to  the  external  surface,  as 
high  as  the  knee,  and  the  apparatus  is  complete.  It  will  be 
observed  that  the  splint  acts  as  a  lever  over  the  outer  ankle, 
which  serves  as  a  fulcrum  to  draw  the  sole  outward  by 
means  of  the  loop  round  its  extremity.  If  the  patient 
walks,  the  splint  is  driven  upward  and  outward,  and  the 
foot  necessarily  follows  it. 

Among  the  machines  which  conform  to  the  deviation  of 
the  foot,  those  of  Bouvier  and  of  Duval  may  be  mentioned. 

The  Machine  of  Bouvier  consists  of  a  jointed  sandal 
attached  to  a  lever,  which,  acting  over  the  ankle,  car- 
ries the  foot  outward  as  its  superior  extremity  approaches 
the  leg. 

The  Apparatus  of  Duval  (Figs.  22,  23)  is  complicated  in 
appearance,  but  is  little  more  than  the  sandal  of  Scarpa's 
boot,  attached  by  a  universal  joint  to  a  leg-piece.  The 
joint  is  governed  by  two  perpetual  screws.  An  upright, 
which  extends  from  the  inner  side  of  the  sole  to  the  ankle, 
is  furnished  with  a  cushioned  metal  plate,  which  may  be  ad- 
vanced against  the  heel  by  screws  from  behind  (Fig.  22,  h). 

The  Apparatus  of  Little,  copied  from  the  Lancet,  Febru- 
ary 24,  1844,  will  be  readily  understood  from  the  drawing 
(Fig.  21). 

VALGUS. 

In  the  simpler  forms  of  valgus,  a  starched  bandage  some- 
times suffices  after  section  of  the  tendo  Achillis.  If  com- 
plicated, the  splint  may  be  used  to  reduce  it  to  the  form  of 
equinus,  as  was  indicated  for  varus.  The  splint  should 
here  be  applied  on  the  internal  surface  of  the  leg. 


CLUB-FOOT.  85 

OTHER    METHODS. 

The  treatment  of  club-foot  by  means  of  a  plaster  mould  has 
been  already  described.  In  the  less  exaggerated  varieties 
of  distortion,  and  especially  in  children,  the  foot  may  be 
gradually  brought  down  by  a  sole,  or  sort  of  shoe,  attached 
to  bands  of  wrought  iron  so  thin  as  to  allow  of  being  bent  to 
the  required  position,  and  stiff  enough  to  retain  it. 

While  the  common  expedients  of  mechanical  treatment 
have  been  described,  it  is  obvious  that  its  purpose  may  be 
equally  effected  by  a  variety  of  combinations,  the  details  of 
which  are  here  unnecessary. 

GENERAL   REMARKS. 

Before  submitting  the  limb  to  the  action  of  a  machine,  es- 
pecially of  the  more  powerful  kind,  it  is  of  great  importance 
that  it  should  be  adequately  protected.  It  should  be  envel- 
oped in  a  soft  roller,  and  afterwards  covered  with  cotton, 
especially  at  the  points  of  puncture.  The  salient  parts  being 
then  wadded,  and  the  cavities  carefully  filled,  the  cotton 
should  be  kept  in  place  by  another  roller.  Any  fold  or 
inequality  is  now  to  be  arranged,  and  the  whole  covered 
with  a  stocking.  The  limb  thus  swathed  is  placed  in  the 
machine,  and  the  straps  successively  fastened.  In  general, 
the  apparatus  should  be  at  first  loosely  applied.  As  the  foot 
becomes  accustomed  to  pressure,  the  straps  may  be  drawn 
tighter,  and  the  force  gently  augmented.  When  the  patient 
complains  of  pain,  relief  is  sometimes  afforded  by  loosening 
the  straps  and  inserting  fresh  wadding.  A  continuance  of 
the  pain  demands  that  the  foot  should  be  removed  from  the 
apparatus,  and  the  skin  exposed,  with  a  view  to  the  local 
treatment  elsewhere  described. 


86  ORTHOPEDIC  SURGERY. 


TORTICOLLIS. 

The  division  of  the  sterno-cleido-mastoid  muscle  with  the 
adjacent  integuments  has  been  performed  by  surgeons  for  the 
last  two  centuries. 

The  operation  by  a  simple  puncture  is  of  more  recent  date. 
Dupuytren  practised  this  method  in  1822,  and  in  1826  and 
1830  Stromeyer  and  Dieffenbach  published  similar  opera- 
tions of  their  own.  In  France  the  method  was  reproduced 
by  Amussat,  Bouvier,  and  Guerin  in  the  years  1836,  1837, 
and  1838.  The  last  named  writer  has  since  materially  mod- 
ified the  operation,  and  has  thrown  much  light  upon  the 
affection  for  which  it  is  practised. 

CAUSES. 

The  agents  of  this  distortion  may  be  considered  in  two 
classes;  the  first  includes  the  varieties  in  which  the  con- 
traction or  retraction  of  the  sterno-cleido-mastoid  is  the 
chief  source  of  the  affection,  while  to  the  second  are  re- 
ferred all  other  causes.  To  the  former,  the  operation  about 
to  be  considered  is  in  most  cases  applicable ;  to  the  latter, 
much  less  frequently.     Among  this  latter  class  are:  — 

Caries  of  the  bone,  —  indicated  especially  by  the  history 
of  the  lesion. 

An  inflammation  of  the  synovial  capsules  and  fibrous 
tissues  of  the  cervical  vertebrae,  which  Bouvier  has  called 
articular  torticollis.  It  is  either  acute  or  chronic.  Distor- 
tion results  from  the  long  continued  efforts  of  the  patient  to 
i-elieve  the  tense  and  painful  ligaments,  by  displacing  them 
in  a  direction  which  the  head  ultimately  retains. 

Abscesses  and  cicatrices  in  the  cervical  region. 

Tumors  and  glandular  engorgements,  so  considerable  as 
to  force  the  head  for  a  length  of  time  from  its  normal  posi- 


TORTICOLLIS.  87 

tion.  To  this  last  cause  Duval  attributes  thirty  out  of  sixty 
cases  treated  by  himself,  and  in  which  the  disease  was  fol- 
lowed in  two  or  three  months  by  permanent  shortening  of 
the  muscles.^ 

Paralysis  of  the  muscles  of  one  side,  the  head  yielding  to 
the  unantagonized  force  exerted  by  the  opposite  side.  The 
cervical  column  is  not  curved,  but  the  last  cervical  is  in- 
clined upon  the  first  dorsal  vertebra.  In  efforts  to  bow  the 
head,  the  chin  turns  to  the  paralyzed  side.  In  this  form 
the  distortion,  if  exaggerated,  may  be  partially  relieved  by 
a  section  of  the  healthy  muscle. 

The  principal  causes  which  directly  affect  the  muscle 
are:  — 

Active  muscular  contraction,  with  subsequent  retraction, 
atrophy,  and  fibrous  transformation.  To  this  agency  most 
cases  of  congenital  torticollis  are  due. 

Muscular  rheumatism  of  the  sterno-cleido-mastoid  muscle, 
and  the  retraction  which  may  result  from  it. 

The  action  of  forceps  applied  during  labor.  The  muscle 
is  torn,  and  blood  effused,  much  as  when  subcutaneously 
divided.  Simple  contusion  sometimes  suffices  to  produce 
inflammation,  followed  by  retraction. 

The  deviation  is  more  frequent  to  the  right  than  to  the 
left.  According  to  Phillips,  two  thirds  of  the  cases  of  this 
distortion  due  to  muscular  contraction  are  directed  to  this 
side ;  and  in  connection  with  the  last  cause  of  the  lesion,  it 
may  be  mentioned  that  in  seventy  per  cent  of  ordinary  labors 
the  head  is  presented  in  the  "first  position." 

The  form  of  torticollis  about  to  be  considered  recognizes 
muscular  retraction  as  its  immediate  cause.  The  muscles  are 
either  idiopathically  affected,  or  are  retracted  at  a  period  sub- 
sequent to  the  original  lesion ;  so  that  the  head,  for  a  length 
of  time  displaced,  by  glandular  enlargement  or  otherwise, 

1  Op.  cit.,  p.  513. 


88  ORTHOPEDIC  SURGERY. 

is  retained  in  its  abnormal  position  by  the  muscular  fibres, 
which  accommodate  themselves  to  their  new  relations. 

SYMPTOMS. 

The  head  deviates  in  various  degrees,  to  the  right  or  left  of 
the  normal  position.  In  the  exaggerated  forms,  the  chin  is 
raised  in  the  air,  while  the  head  is  rotated,  and  depressed 
upon  the  shoulder  of  the  affected  side.  In  this  situation  the 
face  changes  its  expression ;  the  features  of  the  depressed 
side  become  in  a  measure  atrophied ;  the  brow  falls,  and  the 
cheek  becomes  less  prominent. 

In  the  region  of  the  sterno-cleido-mastoid  muscle  a  dense 
cord  is  felt,  which  becomes  more  prominent  and  resisting 
if  force  be  applied  to  the  head  in  a  direction  opposed  to  its 
action. 

The  shoulder  of  the  contracted  side  is  drawn  upward  and 
forward,  so  that  the  sternum  and  the  centre  of  the  thorax, 
being  no  longer  upon  the  same  plane  with  the  shoulder,  are 
apparently  depressed.  Much  pain,  with  a  sensation  of  drag- 
ging, is  sometimes  experienced  in  the  affected  side,  increased 
by  atmospheric  influences,  after  exertion,  and  in  bed. 

STERNO-CLEIDO-MASTOID    MUSCLE. 

M.  Guerin  considers  this  a  double  muscle,  of  which  the  two 
parts,  endowed  with  different  functions,  may  be  separately 
affected. 

The  following  are  his  propositions :  ^  — 

The  sterno-cleido-mastoideus  consists  of  two  distinct  mus- 
cles, the  sterno-mastoideus  and  the  cleido-mastoideus. 

The  sterno-mastoideus  and  the  cleido-mastoideus  are  pos- 
sessed of  separate  functions.  The  first  is  especially  a  motor 
of  the  head,  the  other  is  essentially  an  inspirator  muscle. 

1  Memoire  sur  une  Nouvelle  Metliode  de  Traitement  du  Torticollis 
Ancien,  Paris,  1843,  p.  186. 


TORTICOLLIS.  89 

111  torticollis,  till  now  attributed  to  the  shortening  of  the 
entire  sterno-cleido-mastoideus,  the  sternal  portion  of  the 
muscle  may  be  alone  primitively  affected. 

In  the  treatment  of  chronic  torticollis,  due  to  the  shorten- 
ing of  the  sterno-mastoideus,  the  section  of  the  sternal  por- 
tion may  suffice  for  the  disappearance  of  the  essential  cause 
of  the  deformity. 

The  division  of  the  sternal  insertion  of  the  muscle  is  in 
certain  cases  followed  by  a  more  or  less  gradual  restoration 
of  the  head  to  a  normal  position.  Such  cases  are  reported  by 
Duval  and  other  writers.  In  other  cases  it  is  insufficient,  and 
it  is  necessary  to  divide  the  clavicular  portion  also.  Bonnet  * 
remarks  that  it  is  far  from  sufficing  in  all  cases ;  and  that 
four  times  out  of  five  he  was  compelled  to  divide  the  clavicu- 
lar fasciculus  at  a  later  period  before  the  distortion  yielded. 

VERTEBRAL   COLUMN. 

The  head  being  carried  out  of  the  centre  of  gravity,  the 
vertebral  column  institutes  a  series  of  curves  with  a  view  of 
restoring  the  equilibrium.  They  are  of  two  kinds.  The  first 
is  general,  and  involves  all  the  vertebral  articulations. 

The  second,  described  by  Guerin,  is  local,  and  occurs  at  the 
intervals  of  the  last  lumbar  vertebra  with  the  sacrum,  of  the 
eleventh  and  twelfth  dorsals,  and  of  the  seventh  cervical  and 
first  dorsal.  From  this  inclination  of  "locality,"  (which  is  an 
exaggeration  of  the  normal  movements  of  the  articulations), 
a  series  of  re-entering  angles  results,  common  to  the  spines 
of  all  subjects  affected  with  chronic  torticollis,  and  continuing 
after  the  division  of  the  muscles  of  the  neck. 

TREATMENT    WITHOUT    SECTION, 

Before  the  disease  assumes  a  chronic  form,  while  the  mus- 
cle is  yet  in  a  state  of  simple  contraction,  the  deformity  some- 
times yields  to  medical  treatment,  such  as  kneading,  alternate 

1  Op.  cit.,  p.  582. 


90  ORTHOPEDIC  SURGERY. 

flexion  and  extension,  and  friction.  M.  Guerin  especially 
recommends  local  friction  \vith  the  tartar-emetic  ointment, 
the  development  of  the  pustules  being  sometimes  simulta- 
neous with  the  restoration  of  the  head  to  a  normal  position. 

It  should  be  remarked  that  the  sterno-mastoid  muscle  is 
not  the  sole  cause  of  distortion  in  chronic  cases.  Other 
cervical  muscles  participate  in  the  affection,  and  a  prolonged 
treatment  is  required  to  counteract  their  efforts,  even  after 
the  division  of  the  fibres  of  the  sterno-mastoid.  Neither  is 
the  exaggerated  form  of  distortion  completely  relieved  by 
surgical  aid.  A  certain  inclination  of  the  head  often  con- 
tinues, and  the  features  and  facial  bones,  atrophied  upon  the 
depressed  side,  rarely  regain  their  normal  outline. 

The  age  of  the  patient  is  another  important  consideration. 
M.  Bonnet  places  the  limit  at  fifteen  years ;  after  which  a 
perfect  restoration  of  the  parts,  in  the  chronic  form  of  the 
lesion,  can  no  longer  be  expected. 

SECTION    OP   THE   STERNO-CLEIDO-MASTOID   MUSCLE. 

Before  the  adoption  of  the  subcutaneous  operation,  it  was 
common  to  divide  the  integuments  transversely ;  after  which 
the  muscular  fibres  were  severed,  layer  by  layer.  Such  was 
the  operation  practised  by  Brodie,  Warren,  Eoux,  and  others. 
Of  late  years  the  subcutaneous  method  has  been  generally 
adopted. 

Although  the  section  of  one,  commonly  of  the  sternal  in- 
sertion, sometimes  suffices,  it  is  often  necessary  to  divide  both 
tendons.  Guerin,  who  for  a  time  sustained  the  former  prac- 
tice, has  since  divided,  in  many  cases,  both  fasciculi. 

It  is  usual  first  to  attack  the  most  prominent  of  the  two 
tendons,  after  which  the  other  becomes  more  tense  and  may 
be  divided  either  immediately,  or  after  an  interval  of  a  few 
days  as  suggested  by  Bonnet.  In  certain  cases  the  whole 
muscle  may  be  divided  at  once. 


TORTICOLLIS.  91 

There  has  been  much  discussion  upon  the  merits  of  differ- 
ent sections.  It  has  been  doubted  whether  the  puncture 
should  be  made  from  within  outward,  and  the  section  prac- 
tised from  the  deep  to  the  superficial  parts,  or  vice  versa; 
and  much  unnecessary  importance  has  been  attached  to  these 
differences. 

As  a  general  rule,  the  point  of  section  is  at  a  short  distance 
above  the  sternum.  Guerin  gives  the  distance  of  six  or  eight 
lines  ;  Phillips,  an  inch ;  Duval,  half  or  three  quarters  of  an 
inch.     This  will  evidently  vary  in  different  subjects. 

It  occasionally  happens  that  the  tendon  offers  no  promi- 
nence near  the  clavicle,  and  it  becomes  necessary  to  divide 
it  at  its  most  salient  point,  two  or  three  inches  above.  The 
hemorrhage  which  follows  a  muscular  section  is  sufficient 
reason  for  proscribing  this  point  when  it  can  be  avoided. 
The  section  of  the  superior  extremity  has  long  since  been 
abandoned. 

The  following  are  the  principal  methods. 

Method  of  Dieffenbach. — The  patient  being  seated,  an  aid 
standing  behind  draws  the  head  in  the  direction  opposed  to  the 
deviation,  while  a  second  aid  depresses  the  elbow  and  shoulder 
of  the  affected  side.  The  muscle  being  thus  made  tense,  the 
operator  pinches  it  up  between  his  thumb  and  finger,  and 
passes  a  small  curved  bistoury  beneath  it,  at  a  short  distance 
above  the  sternum.  When  the  point  is  felt  under  the  skin  of 
the  opposite  side,  the  knife  is  slowly  withdrawn,  and  the  mus- 
cle, being  pressed  against  its  edge,  is  in  this  way  severed. 

DuvaVs  Method.  —  The  patient  is  placed  in  the  position 
just  indicated,  and  the  tendon  made  salient.  For  the  sternal 
insertion,  the  tenotome  is  introduced  at  its  posterior  surface, 
from  within  outward.  In  this  case,  the  surgeon  being  in 
front  of  his  patient,  the  right  hand  is  employed  for  the  right 
muscle,  and  the  left  hand  for  the  left.  For  the  clavicular 
insertion,  the  knife  is  introduced  behind   the  most  salient 


92  ORTHOPEDIC  SURGERY. 

edge,  whether  external  or  internal,  and  the  tendon  is  divided, 
from  the  deep  to  the  superficial  layers.  When  the  tendinous 
fasciculus  is  not  marked  beneath  the  skin,  a  puncture  is  made 
with  a  lancet,  through  which  a  blunt  tenotome  is  carried  to 
the  opposite  border  of  the  muscle. 

On  three  occasions  M.  Duval  divided  the  whole  muscle  by 
the  adoption  of  a  single  puncture  at  the  internal  border  of 
the  sternal  insertion,  and  once  by  that  of  a  puncture  at  the 
external  border  of  the  clavicular  extremity. 

Grueriris  Methods.  Sterno-mastoid.  —  The  patient  lies  upon 
a  bed,  the  upper  part  of  which  is  elevated.  An  aid  turns  the 
head  so  as  at  once  to  oppose  the  inclination  and  exaggerate 
the  existing  rotation.  In  this  way  the  muscle  is  extended, 
and  carried  into  an  anterior  plane,  —  detached  as  it  were  from 
the  subjacent  parts.  A  fold  of  skin  is  raised  parallel  with  the 
muscle,  and  the  tenotome  introduced  flatwise,  at  a  point  cor- 
responding, when  the  skin  is  relaxed,  with  the  external  border 
of  the  muscle,  and  six  or  eight  lines  above  its  insertion.  The 
fold  being  released,  the  edge  of  the  tenotome,  previously 
turned  upward,  is  pressed  upon  the  muscle,  which  is  thus  di- 
vided. The  tenotome  here  employed  is  peculiar,  and  concave 
upon  the  edge.     (Fig.  12.) 

In  the  second  method,  less  effectual  than  the  last,  and 
less  employed,  a  convex  tenotome  is  introduced  beneath  the 
tendon.  The  use  of  a  grooved  director  is  objectionable,  upon 
the  ground  that  it  traverses  the  tissues  with  difficulty. 

Cleido-mastoid.  —  The  muscle  being  put  in  tension,  and  a 
fold  raised,  the  instrument  is  introduced  upon  its  inner 
border,  eight  lines  above  its  insertion,  and  the  division  is 
effected  from  the  skin  towards  the  centre ;  so  that  the  two 
insertions  may  be  successively  severed  in  opposite  directions 
by  means  of  a  single  puncture  in  their  interval. 

There  is  little  danger  of  wounding  the  larger  vessels,  es- 
pecially in  the  methods  of  Guerin.     It  has  been  shown  how 


TORTICOLLIS.  93 

the  muscle  is  carried  into  a  plane  anterior  to  these  vessels. 
By  making  the  puncture  near  the  clavicle,  we  avoid  the  an- 
terior jugular  vein  in  its  passage  to  the  subclavian.  The 
primitive  carotid  artery  and  internal  jugular  vein  are  pro- 
tected by  the  sterno-hyoid  and  sterno-thyroid  muscles,  and 
correspond  in  both  sections  to  the  base  of  the  blade  of  the 
knife.  In  dividing  the  cleido-mastoid,  the  anterior  jugular, 
when  it  exists,  may  be  left  between  the  back  of  the  instru- 
ment and  the  skin,  if  the  knife  be  introduced  in  a  position 
perpendicular  to  the  muscular  fibres  and  not  flatwise. 

Should  a  second  section  become  necessary  at  a  subsequent 
period,  certain  precautions  are  requisite.  The  adhesive  action 
and  its  resultant  cicatrix  may  displace  the  larger  vessels,  and 
Duval  suggests  that  an  interval  of  six  months  should  be 
allowed  to  elapse  before  the  section  is  repeated,  in  order 
that  the  newly  formed  substance  may  completely  insulate 
itself  from  the  surrounding  parts. 

The  complete  division  of  the  muscle,  in  all  these  methods,  is 
attended  with  a  slight  snapping  sound,  deepened  by  the  prox- 
imity of  the  chest,  and  also  by  a  sudden  separation  of  the  two 
ends  of  the  divided  muscle  and  a  corresponding  movement  of 
the  head.  As  soon  as  the  knife  is  withdrawn,  the  blood  is  to 
be  expressed  from  the  wound,  and  the  puncture  hermetically 
sealed  with  a  bit  of  adhesive  plaster  of  the  size  of  a  shilling. 
A  compress  and  roller  complete  the  dressing.  Great  care  is 
requisite  to  prevent  the  admission  of  air  into  the  wound.  Pus 
in  this  region  sometimes  infiltrates  the  anterior  mediastinum. 
Once  formed,  the  pus  should  be  allowed  to  escape,  although, 
when  fluctuation  is  first  perceptible,  compression  sometimes 
favors  the  absorption  of  the  fluid.  For  this  purpose,  a  ball  of 
lint  is  placed  upon  the  tumor,  and,  being  covered  with  com- 
presses, is  maintained  by  long  strips  of  adhesive  plaster,  ex- 
tending from  the  back  upon  the  chest. 

With  a  little  attention  to  diet  and  repose,  however,  especially 


94  ORTHOPEDIC  SURGERY. 

if  the  air  has  been  excluded  from  the  wound,  these  accidents 
are  avoided.  The  wound  commonly  heals  by  the  third  day, 
and  mechanical  treatment  may  be  then  commenced. 

SECTION   OF   OTHER   MUSCLES. 

The  division  of  the  sterno-cleido-mastoid  muscle  some- 
times relieves  the  deformity  but  incompletely.  It  is  then 
important  to  ascertain  whether  other  muscular  fibres  aid  in 
retaining  the  head  in  its  abnormal  position,  in  which  case 
they  become  tense,  oppose  any  effort  to  replace  the  head,  and 
require  division.  Portions  of  the  trapezius  and  platysma 
have  been  divided. 

MECHANICAL   TREATMENT. 

The  aim  of  mechanical  treatment  is  twofold.  To  adjust 
the  head  in  a  normal  position ;  to  correct  the  curves  of  the 
vertebral  column. 

When  the  deformity  is  slight,  the  spinal  distortion  is  also 
inconsiderable,  and  attention  should  be  chiefly  directed  to 
the  position  of  the  head  upon  the  cervical  vertebrae.  In  adult 
patients,  and  in  the  exaggerated  varieties,  it  becomes  neces- 
sary to  apply  force  to  the  vertebrte,  both  in  the  cervical  and 
dorsal  regions.     The  apparatus  is  then  complicated. 

Among  the  more  simple  means  of  commanding  the  head 
are  the  following:  — 

A  cravat  of  pasteboard  or  boiled  leather,  as  employed  by 
Guerin,  is  simple,  and  almost  universally  adopted  in  ordinary 
cases.  Its  height  may  vary  at  different  points.  A  substitute 
is  a  circle  of  stiff  wire,  so  bent  as  to  correspond  with  the 
edges  of  such  a  cravat. 

A  band  carried  around  the  head  horizontally,  and  united 
to  vertical  bands  over  the  crown  from  before  backward,  and 
from  ear  to  ear.  A  band  fastened  to  the  first,  at  the  mastoid 
process    of   the  healthy  side,  is  drawn  down  in  front  and 


TORTICOLLIS.  95 

attached  upon  the  chest  or  at  the  waist,  so  as  to  aid  the 
action  of  the  healthy  muscle.  A  cap  may  be  substituted  for 
the  bands  upon  the  head. 

The  temporo-axillary  bandage  of  Mayor.  The  base  of  a 
triangular  handkerchief  is  applied  to  the  temple  of  the 
affected  side,  and  the  extremities  brought,  one  round  the 
forehead,  the  other  round  the  occiput,  to  be  united  below 
the  axilla  of  the  sound  side.  A  horizontal  band  may  be 
added  to  this  bandage. 

The  last  two  methods  tend  rather  to  increase  than  dimin- 
ish the  cervical  inclination,  and  are  therefore  only  appli- 
cable in  slight  deviation,  or  as  temporary  substitutes  for 
other  apparatus. 

A  complete  machine,  the  force  of  which  is  adapted  as  well 
to  the  spine  as  the  head,  is  complicated  and  expensive. 
Various  models  have  at  different  times  been  contrived  for 
this  purpose.  They  are  adapted  either  to  the  horizontal  or 
upright  position.  The  former  have  received  the  name  of 
orthopedic  beds,  and  are  chiefly  modifications  of  those  of 
Shaw  and  of  Guerin. 

An  apparatus  which  permits  locomotion  demonstrates  its 
leading  features  in  the  "  Minerva  "  of  Delacroix,  and  takes 
its  point  of  counter  extension  upon  the  pelvis  or  the 
shoulders. 

The  Apparatus  of  Bouvier,  modified  from  the  Minerva, 
consists  of  a  wide  metallic  belt  resting  upon  the  hips  and 
haunches.  To  this  is  fastened  a  steel  upright  in  the  form  of 
a  T,  which  occupies  the  region  of  the  spine  and  scapulae,  and 
is  retained  by  shoulder  straps.  A  firm  point  of  counter 
extension  is  thus  obtained  between  the  shoulders,  to  which  is 
attached  an  upright  bar,  from  which  the  head  is  suspended. 

The  head  is  secured  by  a  horizontal  metallic  band,  de- 
scending upon  the  mastoid  processes,  which  gives  attachment 
to  vertical  straps  for  the  crown  and  chin.     The  iron  rod  by 


96  ORTHOPEDIC  SURGERY. 

which  it  is  attached  to  the  steel  plate  between  the  shoulders 
is  so  contrived  as  to  admit  of  elongation,  extension,  flexion, 
rotation,  and  lateral  inclination,  in  any  of  which  positions 
it  may  be  fixed.     (Fig.  24. ) 

Cravat  of  PJdllips.  —  A  large  triangular  piece  of  sheet 
iron,  well  cushioned,  is  adapted  to  the  back  of  the  chest,  the 
base  corresponding  to  the  shoulders.  A  strap  confines  it 
around  the  hips.  The  chief  support  is  derived  from  broad 
wadded  suspenders,  which  secure  it  over  the  shoulders.  To 
this  triangle  is  fastened  an  upright  of  iron,  capable  of  being 
raised  or  depressed,  and  terminated  above  by  a  tooth,  corre- 
sponding in  position  and  use  to  the  odontoid  process.  Upon 
this  rotates,  by  means  of  a  socket,  a  stuffed  collar  of  iron 
which  supports  the  chin.  This  contrivance  is  cheap  and 
effectual.      (Figs.  25,  27.) 

The  Orthopedic  Bed  of  Guerin  is  modified  from  that  of 
Shaw.  It  consists  of  a  divided  bed,  of  which  the  superior 
point  of  division  corresponds  to  the  union  of  the  cervical  and 
dorsal  regions,  instead  of  the  central  dorsal  region,  as  in  that 
employed  for  lateral  curvature  of  the  spine.  (Figs.  31,  34.) 
The  body  is  secured  upon  the  bed,  and  appropriate  lateral 
force  is  applied.  The  head  is  confined  in  a  helmet  and  is 
secured  by  a  collar  adjusted  to  the  chin.  The  movements  of 
this  helmet,  which  are  thus  communicated  to  the  head,  are 
universal  and  graduated.  ^ 

An  inclined  plane,  to  the  head  of  which  the  chin  is  at- 
tached by  a  handkerchief  passing  under  it,  is  serviceable  in 
certain  cases.  Extension  is  then  effected  by  the  weight  of 
the  body. 

1  The  details  of  the  machinery,  obvious  to  an  ingenious  mechanist, 
but  requiring  a  long  description,  may  be  found  in  Guerin's  last  edition 
of  "  Torticollis,"  Paris,  1843.  I  am  not  persuaded  that  this  mechanism 
is  the  simplest  and  most  effectual. 


FALSE  ANCHYLOSIS  OF  THE  KNEE  JOINT.  97 


FALSE  ANCHYLOSIS   OF  THE  KNEE  JOINT. 

The  division  of  tendons  is  much  less  effective  in  deformi- 
ties of  the  knee  than  in  those  of  the  foot.  While  club-foot 
depends  in  a  majority  of  cases  upon  muscular  retraction, 
without  lesion  of  the  synovial  surfaces,  distortion  of  the  knee 
rarely  originates  in  this  cause.  It  commonly  results  from 
disease,  either  of  the  cavity  of  the  joint,  or  of  its  investing 
membranes.  Duval  refers  fifteen  cases  in  twenty  to  sub- 
inflammation  of  this  articulation.  The  change  in  the  form 
and  character  of  the  tissues  is  then  so  considerable  as  often 
to  render  it  difficult  to  restore  the  normal  shape  of  the  limb 
or  its  functions.  Most  cases,  however,  are  susceptible  of 
amelioration  from  treatment,  and  it  is  sometimes  possible 
both  to  straighten  the  limb  and  to  restore  its  suspended 
movements. 

CAUSES. 

Congenital  Retraction.  —  This  variety  of  the  affection  is 
analogous  to  other  congenital  deformities,  and  is  accom- 
panied with  the  fibrous  transformation  of  the  retracted  mus- 
cles. As  in  the  operation  for  club-foot,  their  section  then 
facilitates  the  subsequent  mechanical  treatment.  Muscular 
retraction  materially  interferes  with  the  development  of  the 
bones  and  other  parts  in  early  life ;  and  the  limb  rarely  or 
never  regains  its  normal  length  and  outline  if  the  operation 
be  deferred  till  adult  age.  As  an  idiopathic  affection  of  the 
knee,  it  is  comparatively  rare. 

Permanent  Flexion.  —  In  this  position  of  the  leg  the  mus- 
cles become  after  a  time  passively  retracted,  and  require 
equally  division.  It  is  unnecessary  here  to  inquire  what 
agencies  contribute  to  the  position,  so  common  in  chronic 
diseases  of  this  articulation.      By  the  flexion  of  the  knee, 

7 


98  ORTHOPEDIC  SURGERY. 

most  of  the  muscles  are  relaxed.  It  is  the  natural  position 
when  the  patient  lies  on  the  side,  and  the  necessary  one 
when  the  synovial  cavity  is  distended  with  fluid. 

It  is  also  sufficient  to  know  that  in  a  large  majority  of  cases 
of  long  standing,  resulting  from  both  these  causes,  adhesions 
are  formed  between  the  articulating  surfaces;  and  in  this 
connection  it  is  unimportant  whether  they  presuppose  syno- 
vial inflammation,  or  whether,  as  Hunter  suggested,  and  as 
seems  to  follow  from  the  recent  investigations  of  M.  Teis- 
sier, ^  a  simple  state  of  rest  may  cause  vascularity  of  the 
synovial,  and  the  deposit  of  false  membranes. 

Serious  Lesion  of  the  Joint,  —  The  most  common  form  of 
false  anchylosis  is  that  in  which  the  articulating  surface  is 
materially  altered ;  where  chronic  inflammation,  ulceration, 
and  the  lesions  commonly  accompanied  by  the  white  swelling, 
have  occasioned  long  continued  suppuration,  cicatrices  and 
change  in  the  form  of  the  cartilaginous  and  bony  extremities. 

The  following  are  the  principal  changes  which  result  from 
long  continued  flexion  of  the  joint  in  disease  of  this  sort. 

PATHOLOGICAL   ALTERATIONS   OP   THE   TISSUES,   AND   THEIR 
CONSEQUENCES. 

The  entire  limb  is  commonly  withered  and  atrophied. 

Spontaneous  Luxation.  —  The  weight  of  the  flexed  leg  rest- 
ing upon  the  heel  in  a  horizontal  position,  aided  by  the 
action  of  the  flexor  muscles,  inclines  the  head  of  the  tibia 
backward,  and  the  joint  tends  to  open  behind;  while  the 
distended  condition  of  the  lateral  and  posterior  ligaments 
finally  permits  this  bone  to  glide  back  upon  the  posterior 
surface  of  the  condyles  of  the  femur,  which  are  often  atro- 
phied at  that  part. 

Rotation.  — The  powerful  action  of  the  biceps  flexor,  the 
shape  of  the  condyles,  the  disposition  of  the  crucial  liga- 

^  Gazette  Medicale,  torn.  ix.  pp.  609-626. 


FALSE  ANCHYLOSIS  OF  THE  KNEE  JOINT.  99 

ments,  and  the  position  of  the  leg,  which  the  patient  supports 
upon  the  outer  side  of  the  heel,  tend  to  impress  upon  it  a 
movement  of  rotation  outward,  often  considerable.  Duval 
refers  to  a  case  in  which  the  internal  condyle  of  the  femur 
was  received  into  the  external  concave  surface  of  the  tibia, 
there  being  a  semiluxation  of  the  tibia  upon  the  femur. 
These  partial  luxations,  according  to  Bonnet,  accompany 
three  fourths  of  the  cases  of  angular  anchylosis  of  the  knee. 

Outward  luxation  of  the  patella  generally  accompanies 
rotation  of  the  tibia. 

Change  of  Form  in  the  Articulating  Extremities.  —  The 
parts  in  contact  undergo  ulceration  and  absorption.  The 
pressure  of  the  condyles  of  the  tibia,  often  ulcerated  them- 
selves, occasions  extensive  absorption  of  the  posterior  part  of 
the  condyles  of  the  femur,  which  are  sometimes  excavated  to 
the  depth  of  half  an  inch  or  more.  The  pressure  of  the 
patella  upon  the  external  condyle  in  front  destroys  its 
convexity. 

Adhesions.  — The  patella  is  sometimes  glued  to  the  anterior 
part  of  the  femur,  and  sometimes  to  the  interval  between 
the  femur  and  tibia,  in  which  case  it  is  impossible  to 
straighten  the  limb.  The  cartilages  of  the  anterior  part  of 
the  femur  are  sometimes  absorbed,  and  the  two  bones  become 
intimately  united  by  fibro-cellular  bands,  in  a  way  to  oblit- 
erate the  anterior  half  of  the  cavity  of  the  synovial  mem- 
brane.^ Finally,  masses  of  fibrous  tissue  surround  the  joint, 
occupying  especially  the  popliteal  region,  where  they  en- 
velop the  vessels  and  nerves,  and  form  a  compact  mass.  A 
dissection  was  exhibited  by  M,  Chassaignac  to  the  Anatomi- 
cal Society  of  Paris,  in  which  the  popliteal  artery  was  so 
contracted  by  these  adhesions,  and  embedded  in  them,  that 
any  attempt  at  sudden  extension  of  the  limb  must  have  pro- 
duced its  rupture. 

1  Bonnet,  p.  560. 


100  ORTHOPEDIC  SURGERY. 


DIAGNOSIS   OF   THE   DIFFERENT   ORGANIC    LESIONS. 

While  the  disease  is  in  an  active  state,  besides  the  con- 
stitutional symptoms,  the  knee  is  often  much  enlarged.  It 
may  present  the  peculiar  doughy  feeling  which  sometimes 
accompanies  sub-inflammatory  action  in  this  region,  or  may 
be  distended  with  fluid.  There  is  generally  more  or  less 
pain  upon  movement,  however  slight- 
When  the  popliteal  nerve  is  retracted,  probably  by  virtue 
of  its  fibrous  sheath,  it  is  of  manifest  importance  to  distin- 
guish it  from  the  tendons,  which  present  a  similar  elevation 
in  the  ham.  Their  relations,  however,  are  different.  While 
the  tendons  may  be  traced  to  the  condyles  of  the  femur,  the 
nerve  traverses  the  area  of  the  popliteal  triangle  and  occu- 
pies the  space  between  the  condyles. 

The  position  of  the  bones  is  easily  detected.  The  luxation 
and  rotation  of  the  tibia  is  indicated  by  the  corresponding 
and  evident  modification  of  the  outline  of  the  limb,  and  by 
the  outward  direction  of  the  toe,  when  the  anterior  part  of 
the  thigh  is  made  to  look  directly  forward. 

The  absorption  or  disintegration  of  the  articulating  sur- 
faces is  difficult  to  be  detected,  and  must  be  inferred  from 
the  duration  of  the  disease,  the  position  of  the  limb  and  of 
the  patella,  and  from  the  amount  of  suppuration. 

The  existence  of  fibrous  tissues  is  to  be  inferred  from  the 
resistance  of  the  soft  parts,  and  the  cicatrices  of  fistulous 
passages. 

Adhesions  are  less  difficult  to  be  recognized  than  ulcera- 
tions of  the  articulating  surfaces.  The  union  of  the  tibia 
and  femur  is  indicated  by  the  absence  of  all  movement. 
The  adhesion  of  the  patella  should  not  be  confounded  with 
its  immobility  resulting  from  the  tenseness  of  the  ligaments 
when  the  leg  is  flexed.     When  the  patella  is  adherent,  we 


FALSE   ANCHYLOSIS  OF  THE   KNEE  JOINT.  101 

may  always  infer  the  obliteration  of  the  anterior  part  of  the 
cavity  of  the  joint.  ^ 

It  is,  however,  in  some  cases  difficult  to  distinguish  true 
from  false  anchylosis,  — the  bony  from  the  fibrous  union  of 
the  parts.  The  pain  produced  by  the  forced  flexion  of  the 
joint  is  an  uncertain  test.  Perhaps  the  surest  indication  that 
the  union  is  false  is  the  possibility  of  still  producing  a  cer- 
tain amount  of  flexion  beyond  the  point  at  which  the  knee  is 
stationary,  and  hindered  from  extension  by  the  retracted 
muscles.  The  limb  can  then  in  most  cases  be  straightened. 
But  when  the  joint  is  entirely  deprived  of  the  power  of  flexion, 
it  is  probable  that  the  anchylosis  is  bony;  and  in  such  cases, 
even  when  the  osseous  deposit  is  inconsiderable,  it  is  doubt- 
ful if  the  degree  of  flexion  has  ever  been  diminished.  It  is 
of  less  importance  to  distinguish  true  anchylosis,  imperfect 
though  it  be,  from  the  complete  fibrous  union  of  the  syno- 
vial surfaces  which  sometimes  follows  rheumatic  affection, 
since  this  lesion  also  offers  serious  obstacles  to  mechanical 
treatment. 

Passive  flexion  of  the  joint  is  sometimes  diminished,  or 
entirely  prevented,  during  the  examination  of  the  patient, 
by  the  active  contraction  of  the  muscles,  so  that  capability  of 
motion  may  exist  where  it  is  not  detected.  In  such  cases,  if 
the  attention  of  the  patient  be  diverted,  the  muscles  become 
relaxed,  and  a  certain  power  of  movement  is  found  still  to 
exist ;  but,  as  was  before  stated,  it  is  commonly  in  the  direc- 
tion of  flexion,  extension  being  prohibited  by  the  passively 
contracted  muscles.  In  examining  the  limb,  the  alternate 
forced  movement  which  stimulates  the  contraction  of  the 
muscles  may  be  estimated,  by  measuring,  as  Duval  recom- 
mends, the  distance  between  the  ischium  and  heel,  in  each 
position,  the  pelvis  being  fixed.  If  there  is  a  difference  in 
the  measurements,  the  union  is  false. 
1  Bonnet,  p.  571. 


102  ORTHOPEDIC  SURGERY. 


TREATMENT. 


The  treatment  of  false  anchylosis  of  the  knee  joint  may  be 
considered  under  three  general  heads:  — 

The  division  of  the  tendons  which  oppose  extension. 

The  extension  of  the  limb. 

The  reproduction  of  its  normal  movements. 

The  evidence  of  the  results  of  treatment  is  far  from  satis- 
factory. Thus,  in  the  serious  lesion  of  the  joint  already 
alluded  to,  Bonnet  maintains  that  the  section  of  tendons 
is  never  practised  with  success ;  Phillips  is  less  decided  as 
to  the  efficacy  of  treatment,  while  Duval  offers  numerous 
observations  of  distortion  from  lesion  of  this  sort,  accom- 
panied with  suppuration  and  subsequent  cicatrices,  in  which 
treatment  produced  a  straight  and  serviceable  limb. 

The  results  of  these  cases  seem  to  have  varied,  not  only 
with  the  character  and  degree  of  the  lesion,  but  with  the 
nature  of  the  mechanical  treatment;  and  it  is  therefore 
important  to  estimate  the  value  both  of  the  indications  for 
treatment  and  of  the  different  methods  of  applying  mechani- 
cal force. 

Of  the  former,  one  of  the  most  promising  is  the  possibility 
of  still  executing  a  certain  degree  of  flexion.  Duval  does 
not  hesitate  to  affirm  that  by  means  of  subcutaneous  sec- 
tions entire  extension  can  always  be  obtained,  provided  the 
anchylosis  is  false  or  incomplete.  But  it  is  evident  that, 
without  the  indication  afforded  by  the  capability  of  flexion, 
it  is  difficult,  if  not  impossible,  to  establish  this  important 
point.  There  is  little  or  no  recorded  evidence  to  show  that 
the  limb  has  ever  been  reinstated  when  the  joint  was  en- 
tirely destitute  of  the  power  of  motion,  that  is,  of  flexion; 
while,  on  the  contrary,  it  frequently  happens  that  all  efforts 
fail  to  produce  any  modification  in  the  outline  of  the  limb. 
The  cavity  of  the  joint  has  then  become  the  repository   of 


FALSE  AIJCHYLOSIS  OF  THE  KNEE  JOINT.  103 

organized  lymph,  which  has  soldered  together  the  articulat- 
ing surfaces.^  In  time,  this  lymph  is  transformed  Into  bone, 
and  the  anchylosis  is  complete. 

But  it  does  not  theoretically  follow,  in  the  absence  of 
facts,  that  treatment  must  be  unavailing  because  there  is 
no  movement  in  the  joint,  even  at  a  period  when  the  lymph 
presents  some  traces  of  osseous  deposit.  Nor  are  the  experi- 
ments of  M.  Bonnet  upon  the  dead  subject  conclusive. ^  The 
organized  false  membrane,  while  endowed  with  vital  proper- 
ties, must  tend  to  yield  to  a  permanent  and  proportionate 
force,  to  be  relaxed  by  gradual  traction,  and  to  be  absorbed 
by  pressure.  In  this  way,  continued  mechanical  force  is 
capable  of  producing  effects  upon  the  living  tissues  which 
the  passive  resistance  of  dead  and  inert  fibres  would  render 
impossible.  In  such  cases,  experiment  alone  can  decide  upon 
the  propriety  or  the  efficacy  of  treatment. 

Interarticular  adhesions  are  not  the  only  obstacles  to 
the  successful  treatment  of  this  deformity.  An  equal,  and 
according  to  some  writers  a  greater  difficulty,  exists  in 
the  distortion  of  the  articulating  surfaces.  Nor  is  the 
amount  of  this  distortion  indicated  by  the  degree  of  flexion 
of  which  the  joint  is  capable ;  for,  as  Duval  affirms,  the  Joint 
may  enjoy  this  power  to  a  considerable  extent  where  the 
alteration  of  the  articulation  is  sufficient  to  interfere  mate- 
rially with  treatment.  When  the  luxation  is  great,  and 
when  the  condyles  are  partially  absorbed,  it  sometimes 
happens  that  all  attempts  at  extension  are  fruitless ;  either 
because  the  adhesions  are  too  firm  to  be  overcome,  or  because 

^  I  have  examined  a  knee  in  this  state  in  which  there  was  no  possi- 
bility of  producing  movement,  though  as  yet  no  osseous  particles  had 
been  deposited. 

2  In  these  attempts  to  straighten  the  limb  it  was  found  necessary,  not 
only  to  divide  the  tendons  and  fibrous  tissues,  but  also  to  open  the  joint 
behind,  in  order  to  allow  the  postei'ior  edge  of  the  articulating  surface  of 
the  tibia  to  recede  from  the  femur.     Op.  cit.,  p.  563. 


104  ORTHOPEDIC  SURGERY. 

the  patella  has  engaged  itself  between  the  tibia  and  femur, 
and  cannot  be  displaced.^ 

The  condition  of  the  articulation  also  exercises  an  im- 
portant influence  upon  the  shape  of  the  limb  after  treatment. 
This,  however,  depends  not  only  upon  the  degree  of  luxation 
and  rotation  of  the  tibia,  upon  the  amount  of  ulceration  and 
absorption  of  the  cartilage  and  bone,  but  also  upon  the 
direction  and  adjustment  of  the  mechanical  force  employed 
during  the  treatment. 

The  tendency  of  the  tibia  to  backward  luxation  has  been 
referred  to.  If  in  permanent  flexion  of  this  sort  an  extend- 
ing force  be  applied  to  the  foot,  the  head  of  the  tibia  does  not 
slide  forward  on  the  condyles  of  the  femur,  as  in  the  normal 
condition  of  the  joint,  but  tends  to  remain  stationary  behind 
it.  The  anterior  margin  of  its  articulating  surface  forms, 
against  the  femur,  a  fulcrum  by  which  the  posterior  edge  is 
gradually  lifted  away  from  the  condyles ;  so  that  when  the 
limb  is  straight,  the  perpendicular  of  the  tibia  is  behind 
that  of  the  femur,  and  the  weight  of  the  body  resting  on  the 
femur  bears  upon  a  point  anterior  to  the  head  of  the  tibia. 

This  is  the  condition  of  the  leg  in  a  large  proportion  of  the 
cases  mentioned  by  Duval.  Mr.  Little  seems  to  have  obtained 
better  results,  the  tibia  being  made  to  occupy  a  position 
more  directly  beneath  the  femur.  The  advantage  in  the 
treatment  adopted  by  the  latter  surgeon  is  mainly  due  to  the 
distribution  of  force  in  the  machines  employed.  While  that 
of  Duval  merely  extends  the  limb,  the  apparatus  used  by 
Little  aims  both  at  extension  and  at  the  reduction  of  the 
head  of  the  tibia,  which  is  pushed  into  its  place  by  an  effort 
applied  directly  to  it.  In  fact,  without  this  arrangement, 
the  previously  existing  luxation  is  liable  to  be  exaggerated, 
and  even  to  be  rendered  complete. 

The  degree  of  movement  permitted  to  the  joint  after  reduc- 
1  Phillips,  op.  cit.,  p.  201. 


FALSE  ANCHYLOSIS  OF  THE  KNEE   JOINT.  105 

tion  depends  chiefly  upon  the  degree  of  the  lesion,  but  also 
partly  upon  the  treatment.  In  Duval's  cases,  six  patients 
out  of  ten  were  left  with  a  stiff  joint ;  but  it  should  be  re- 
membered that  this  surgeon  considers  the  treatment  com- 
plete when  the  limb  is  brought  down  and  the  patient  is  able 
to  rest  his  weight  upon  it.  Little,  on  the  contrary,  here 
commences  a  third  stage  of  treatment,  with  the  view  of  re- 
establishing the  movements  of  the  articulation,  and  he  seems 
in  some  cases  to  have  obtained  this  desirable  result. 

When  the  deformity  occurs  at  an  early  age,  especially 
when  it  is  congenital,  and  depends  upon  muscular  contrac- 
tion, it  is  of  great  importance  not  to  delay  treatment.  The 
retracted  muscles  prevent  the  bones  from  attaining  their 
normal  growth  in  length,  and  irremediable  deformity  is  the 
consequence.  In  May,  1838,  M.  Bouvier  exhibited  to  the 
Academic  des  Sciences  a  specimen  which  demonstrated  these 
consecutive  changes  of  bones  and  ligaments,  and  the  neces- 
sity of  early  action  to  anticipate  such  alterations. 

Duval  fixes  the  average  duration  of  treatment  at  six  weeks, 
and  the  maximum  at  three  or  four  months,  while  Little 
places  the  average  in  adults  at  two  months,  a  shorter  period 
being  necessary  for  children.  The  process  of  restoring 
mobility  requires  from  three  months  to  a  year. 

MEDICAL   TREATMENT. 

It  is  sometimes  well  to  fortify  the  general  health  of  the 
patient,  who  is  often  of  a  scrofulous  constitution ;  and  also 
to  reduce,  if  necessary,  the  local  inflammation,  before  sub- 
mitting the  limb  to  surgical  influences. 

Duval  recommends  for  this  purpose  a  course  like  the  fol- 
lowing. Salt-water  baths  every  two  days,  if  practicable  in 
the  open  air  and  sun ;  three  or  four  cups  daily  of  infusion 
of  hops,  with  ten  grains  of  carbonate  of  soda,  or  a  dozen 
pastilles  of  lactate  of  iron ;  claret  wine,  diluted  with  infusion 


106  ORTHOPEDIC  SURGERY 

of  hops  at  meals  j  broiled  or  roast  meat;  no  milk  or  fruits. 
In  short,  a  tonic  and  anti-scrofulous  regimen. 

At  night,  a  poultice  to  the  knee  made  with  a  narcotic 
decoction. 

Every  morning,  on  removing  the  poultice,  friction  of  the 
joint  with  a  bit  of  the  following  ointment  of  the  size  of  a 
filbert: — 

Simple  cerate  §  ii. 

Bromide  of  iron  3ii. 

Extract  of  hemlock  )  ,7 . . . 

>  aa   0111. 
Camphor  ) 

For  the  bromide  of  iron  eight  grains  of  iodine,  with  a 
dram  of  hydriodate  of  potassa,  may  be  substituted  if  slight 
irritation  of  the  surface  be  desired;  or  two  drams  of  the 
iodide  of  lead,  as  a  simple  resolutive  producing  no  cuta- 
neous irritation. 

SURGICAL  TREATMENT. 

Under  this  head  will  be  successively  considered  treat- 
ment without  tenotomy ;  the  section  of  tendons ;  sudden  ex- 
tension ;  gradual  extension  after  the  inflammatory  symptoms 
have  subsided ;  tenotomy  and  extension  during  the  existence 
of  local  inflammation. 

TREATMENT  WITHOUT  TENOTOMY. 

What  has  been  already  said  upon  this  point  in  connec- 
tion with  Torticollis  and  Club-foot  applies  equally  to  False 
Anchylosis.  The  resistance  of  the  muscles,  when  recently 
contracted,  may  undoubtedly  be  overcome  by  simple  exten- 
sion. According  to  Little,  we  may  succeed  in  effectually 
straightening  the  limb  without  tenotomy  in  a  favorable  case 
of  false  anchylosis  in  the  adult,  even  after  the  lapse  of  five 
years ;  but  it  is  rarely  possible  in  a  child,  unless  of  very  lax 
fibre,  to  relieve  permanently  by  mechanical  means  a  severe 


FALSE   ANCHYLOSIS  OF  THE   KNEE  JOINT.  107 

contraction  of  similar  duration.  The  fibrous  transformation 
is  more  rapidly  effected  in  children ;  partly  because  the  func- 
tions are  in  general  more  active,  and  partly  perhaps  because 
the  muscle  is  subjected  to  increasing  tension  as  the  bones 
are  developed. 

THE   SECTION    OF   TENDONS. 

The  tension  of  the  muscles,  and  the  resistance  which  they 
offer  to  extension,  is  of  course  the  immediate  indication  for 
tenotomy.  In  the  congenital  form,  tenotomy  is  especially 
indicated.  When  the  retraction  is  only  passive  and  a 
sequence  of  permanent  flexion,  the  duration  of  the  lesion 
will  give  some  indication  of  the  probable  degree  of  fibrous 
transformation  and  the  propriety  of  tenotomy.  In  most 
chronic  cases,  extension  is  facilitated  and  the  treatment  is 
abridged  by  dividing  the  tendons  of  the  ham ;  but  the  more 
important  element  of  prognosis,  the  condition  of  the  ar- 
ticulation, must  be  taken  into  the  estimate  in  deciding  the 
question  of  treatment. 

The  section  of  the  tendons  which  oppose  the  extension  of 
the  leg  seems  to  have  been  first  effected  by  Michaelis, 

Dieffenbach  operated  in  1830,  Duval  in  1837,  Bouvier  in 
1838,  and  Guerin  in  1839. 

The  chief  varieties  in  the  method  of  operating  are  those  of 
Dieffenbach  and  Bouvier;  the  former  of  whom  divided  the 
tendons  from  the  deep  to  the  superficial  regions,  the  latter 
in  the  inverse  direction. 

Method  of  Dieffenbach.  — The  patient,  supported  by  an 
aid,  is  placed  upon  his  knees  in  a  chair,  while  a  second  as- 
sistant controls  the  thigh  of  the  affected  side.  The  operator 
first  divides  the  tendons  of  the  semi-membranosus  and  semi- 
tendinosus  in  carrying  the  instrument  beneath  the  skin  and 
beneath  the  tendons.  The  biceps  is  divided  in  the  same  way. 
The   extension   is  then  increased  to  bring  into   view   any 


108  ORTHOPEDIC  SURGERY. 

fibres  which  may  still  oppose  the  straightening  of  the  limb, 
and  these  are  then  successively  divided.  The  punctures  are 
carefully  closed,  and  the  other  requirements  of  subcutaneous 
wounds  as  far  as  possible  fulfilled. 

MetJiod  of  Duval.  —  The  patient  lies  upon  his  belly,  and 
the  leg  is  extended.  The  tenotome  is  introduced  at  the 
level  of  the  tendons  and  towards  their  anterior  face,  the  most 
prominent  of  which  is  first  to  be  divided.  The  leg  is  then 
farther  extended,  and  other  tendons  become  in  their  turn 
salient.  The  first  is  commonly  the  biceps,  the  second  the 
semi-tendinosus,  then  the  semi-membranosus. 

For  the  former,  the  instrument  should  be  introduced  from 
the  hollow  of  the  ham  outwards,  and  as  far  down  as  possible, 
to  avoid  lesion  of  the  vessels  and  nerves.  Two  punctures 
suffice ;  one  for  the  biceps,  and  one  for  the  other  two  mus- 
cles. The  knife  should  not  be  allowed  to  perforate  the 
opposite  surface.  It  is  made  to  bear  directly  upon  the  ante- 
rior part  of  the  tendon,  which  is  divided  from  its  deep  to 
its  superficial  and  cutaneous  surface.  The  pain  is  slight, 
a  few  drops  of  blood  only  escape,  and  the  punctures  heal  in 
two  days. 

Method  of  Bouvier.  — Longitudinal  punctures  are  made 
upon  the  eccentric  border  of  the  tendons  to  be  divided. 
A  blunt  tenotome  is  introduced  flatwise  beneath  the  skin, 
while  the  finger  of  the  left  hand  of  the  operator  apprises  him 
of  the  progress  of  the  instrument.  It  is  then  turned  upon 
the  tendon,  which  is  divided  from  without  inward.  The 
edge  of  the  instrument  should  be  so  short  as  neither  to 
enlarge  with  its  base  the  external  aperture,  nor,  in  dividing 
the  biceps,  to  wound  with  its  extremity  the  external  popliteal 
nerve.  From  the  puncture  of  the  outer  surface  the  biceps  is 
divided;  from  the  internal  puncture,  the  semi-tendinosus, 
semi-membranosus,  and,  if  required,  the  rectus  internus. 

According  to  M,   Bonnet,  it  is  necessary  in  certain  cases 


FALSE  ANCHYLOSIS  OF  THE  KNEE  JOINT.  109 

to  divide  not  only  the  rectus  internus  and  sartorius,  but  the 
gastrocnemius,  which  last  is  effected  by  severing  the  tendo 
Achillis. 

From  the  dissections  of  this  surgeon  it  appears  that  the 
nerves  are  also  sometimes  so  retracted  as  to  resemble  ten- 
dons. They  may  be  distinguished,  as  was  before  stated, 
from  the  tendons,  which  pass  to  a  point  just  inside  the  con- 
dyles of  the  femur,  by  their  position  in  the  centre  of  the 
lower  part  of  the  popliteal  space. 

The  larger  vessels  are  deeply  seated ;  but  the  proximity  of 
the  popliteal  nerve  to  the  outer  hamstring  is  sufficient  reason 
for  preferring  the  method  of  Dieffenbach,  which  protects  it 
with  the  back  of  the  instrument,  to  that  of  Bouvier,  which 
exposes  it  to  the  edge. 

In  certain  cases,  the  section  of  the  biceps  alone  suffices, 
especially  in  the  variety  complicated  with  inward  deviation; 
but  it  not  unfrequently  happens  that  the  semi-tendinosus 
and  semi-membranosus  become  prominent  a  week  or  two 
afterwards,  and  require  division. 

From  the  internal  puncture  may  be  successively  divided 
the  semi-membranosus,  which  is  deepest,  then  the  semi- 
tendinosus,  and  finally  the  rectus  internus.  Resting  here, 
we  avoid  the  section  of  the  internal  saphenous  nerve,  but  in 
dividing  the  sartorius  this  nerve  and  the  vein  are  necessarily 
comprised  in  the  section. 

It  is  asserted  by  Little  that  it  is  better  to  divide  the  super- 
ficial  and  cutaneous  nervous  filaments  which  traverse  the 
surface  of  the  gastrocnemius.  They  may  be  distinguished 
from  fibrous  filaments  by  the  peculiar  pain,  sometimes  severe, 
occasioned  by  their  tension,  especially  during  treatment. 

Professor  Froriep  of  Berlin  reports  a  case  in  which  the 
fascia  lata  and  fascia  cruralis  required  division.  Such  cases 
are  comparatively  rare. 


no  ORTHOrEDIC   SURGERY. 

MECHANICAL   TREATMENT   OF    CHRONIC    FALSE    ANCHYLOSIS. 

Two  kinds  of  mechanical  treatment  have  been  applied  to 
false  anchylosis :  immediate  and  gradual,  or,  in  other  words, 
violent  and  progressive. 

Among  the  first  are  to  be  ranked  the  methods  of  Dieffen- 
bach  and  Louvrier.  The  second  includes  the  methods  of 
Duval,  Bouvier,  and  others. 

SUDDEN   EXTENSION. 

The  method  of  Dieffenbach  differs  from  that  of  Louvrier. 
While  the  former  divides  the  tendons  and  then  violently 
flexes  the  limb,  Louvrier  directs  the  effort  to  its  extension, 
and  without  section  of  the  tendons.  In  the  one  case,  the 
punctures  of  the  integuments  are  liable  to  laceration ;  in  the 
other,  the  tendons  are  almost  of  necessity  ruptured. 

Method  of  Dieffenbach.  —  Immediately  after  the  division  of 
the  resisting  tendons  and  fibres,  and  also  of  any  deep-seated 
cicatrices  which  offer  impediment  to  extension,  the  operator 
places  one  hand  upon  the  thigh  of  the  patient,  and  with  the 
other  seizes  the  foot  and  forcibly  flexes  the  limb.  It  is  then 
alternately  flexed  and  extended,  the  principal  effort  bearing 
upon  the  flexion.  To  effect  this  the  united  force  of  two  or 
three  men  is  sometimes  requisite. 

The  rupture  of  the  adhesions  is  attended  with  cracking 
explosions.  The  punctures,  covered  during  the  operation  by 
the  fingers  of  the  operator  to  exclude  the  air,  are  now  closed 
with  sticking  plaster,  and  the  limb  enveloped  in  a  roller  is 
placed  in  a  splint. 

It  sometimes  happens  that  the  limb  persistently  returns 
to  a  state  of  flexion  after  extension,  a  movement  due  to  the 
retraction  of  the  lateral  ligaments.  The  external  ligament 
is  commonly  the  one  affected,  and  is  then  perceptible  beneath 
the  skin,  and  requires  division. 


FALSE   ANCHYLOSIS  OF  THE   KNEE   JOINT.  Ill 

Method  of  Louvrler.  —  The  barbarous  method  of  M.  Lou- 
vrier  needs  but  brief  notice.  The  limb  is  confined  in  splints 
hinged  at  the  knee.  The  patient  is  placed  in  a  recumbent 
position,  and  forcible  extension  is  applied  at  two  points  by 
means  of  cords  wound  around  a  drum.  By  one  the  foot  is 
drawn  down,  while  the  other  simultaneously  depresses  the 
knee  towards  a  straight  line.  Extension  is  thus  effected  in 
twenty-five  or  thirty  seconds;  but  not  without  rupture  of 
the  skin  and  of  the  tendons  of  the  ham,  denudation  of  the 
vessels  and  nerves,  gangrene,  and  in  one  instance  suppura- 
tion and  death  on  the  twenty-second  day.  In  another  case 
the  artery  was  ruptured,  gangrene  ensued,  and  amputation 
was  rendered  necessary. 

The  method  of  Dieffenbach  is  not  exempt  from  accidents. 
Duval  reports  a  case  of  fever,  local  suppuration,  and  delirium 
following  the  operation.  ^ 

Such  results  peremptorily  forbid  the  adoption  of  these 
methods  in  chronic  cases,  especially  as  equal  advantage  is 
to  be  derived  from  a  gradual  and  much  less  painful  applica- 
tion of  force. 

In  recent  cases  of  not  more  than  three  or  four  months 
standing  and  the  result  of  acute  inflammation,  circumstances 
may  render  it  expedient  to  break  the  adhesions  by  sudden 
force,  but  even  then  gradual  extension  is  to  be  preferred  in 
a  majority  of  instances.  In  such  an  event,  when  the  in- 
flammation has  subsided,  manual  force  may  be  applied  as 
described  by  Bonnet. 

For  this  purpose,  the  flexors  of  the  leg  are  relaxed  by  a 
horizontal  position  of  the  patient.  An  aid  controls  the 
pelvis,  while  another  supports  the  foot.  The  surgeon  now 
with  one  hand  pushes  the  head  of  the  tibia  forward,  to 
counteract  its  backward  luxation,  while  with  the  other  he 
depresses  the  inferior  extremity  of  the  femur.     The  limb, 

^  Op.  cil.,  p.  455. 


112  ORTHOPEDIC   SURGERY. 

when  reduced,  is  placed  in  a  hollow  splint,  and  enveloped 
in  a  starched  bandage. 

Slowly  Progressive  Extension.  —  In  this  method,  the  two 
portions  of  the  limb  are  confined  in  splints,  hinged  at  the 
knee,  and  brought  into  a  straight  line  by  long  continued 
traction  or  other  mechanical  means.  The  rectification  is 
often  completed  in  less  than  a  month  after  the  division  of 
the  tendons.  In  exceptional  cases  it  requires  three  or  four 
months. 

In  the  application  of  these  machines,  care  should  be  taken 
to  distribute  and  equalize  the  force.  It  has  been  elsewhere 
shown  that  the  tibia  is  disposed  to  backward  luxation,  and 
often  requires  to  be  pressed  forward  at  the  moment  extension 
is  applied.  Perhaps  the  best  machine  is  that  described  by- 
Little.  The  apparatus  of  Bonnet,  which  resembles  the  appa- 
ratus of  Louvrier,  and  imitates  the  manner  already  described 
of  applying  manual  force,  is  also  efficient. 

The  punctures  are  allowed  to  cicatrize,  and  the  limb  is 
well  protected  with  cotton  before  being  submitted  to  the 
machine.  A  flannel  roller  is  then  applied,  somewhat  tighter 
at  the  knee  than  above  or  below,  to  aid  in  counteracting  the 
tendency  to  flexion.  Extension  at  first  progresses  rapidly, 
even  when  the  flexion  is  considerable  to  the  extent  of  thirty 
or  forty  degrees  in  a  week ;  but  is  subsequently  more  gradual 
and  laborious. 

When  the  knee  becomes  painful  and  engorged,  Duval 
advises  local  friction,  with  the  ointment  of  iodide  of  lead 
already  mentioned,  and  compression  by  means  of  a  flannel 
roller.  The  machine  is  then  reapplied.  Pain  is  always  an 
indication  for  the  removal  of  the  apparatus  and  examination 
of  the  limb,  as  in  the  treatment  of  club-foot.  When  the 
sections  are  recent,  a  slight  movement  of  the  limb  is  apt  to 
occasion  great  suffering.  It  should,  therefore,  be  well 
supported  while  the  apparatus  is  being  changed. 


FALSE  ANCHYLOSIS  OF   THE   KNEE  JOINT.  113 

It  may  sometimes  be  optional  with  the  patient  whether  the 
limb  shall  be  entirely  reduced,  or  whether  it  shall  remain 
flexed  at  a  slight  angle,  the  latter  position  being  undoubtedly 
the  most  convenient,  especially  in  ascending  a  hill  or  going 
up  stairs. 

Different  machines  will  be  found  described  in  the  plates. 
(Figs.  26,  28,  29,  30.) 

RESTORATION   OP   MOBILITY. 

After  rectification,  Little  commences  a  new  treatment  for 
the  purpose  of  restoring  the  mobility  of  the  joint.  The 
method  consists  of  passive  movements,  frictions,  vapor  baths, 
etc.,  with  occasional  flexion  and  extension  by  means  of  a 
machine  applied  to  the  leg.  This  tedious  process  requires 
a  period  varying  from  three  to  six,  and  even  twelve  months. 

MECHANICAL  TREATMENT  WITH   TENOTOMY  DURING   INFLAMMATION. 

In  certain  cases  anchylosis  must  be  considered  as  a  favor- 
able termination  of  the  disease.  To  interfere  with  the 
process  would  renew  the  inflammation.  Little  considers 
tenotomy  inapplicable  until  two  or  three  years  after  the  ter- 
mination of  active  inflammatory  symptoms,  and  cites  a  case 
in  which  disease  was  reproduced,  apparently  from  a  neglect 
of  this  rule. 

M.  Duval  maintains  an  opposite  theory,  and  while  he 
deprecates,  in  such  cases,  unaided  mechanical  treatment,  he 
maintains,  in  a  memoir  addressed  to  the  Academy  of  Sci- 
ences in  December,  1841,  that  "club-feet  and  false  angular 
anchyloses  of  the  knee  may  be  cured  during  the  course  of 
the  inflammatory  maladies  which  produced  them. "  The  fol- 
lowing passage  more  fully  illustrates  this  point:  — 

"  When  there  is  an  inflammation  of  the  knee,  the  seat  of 
which  is  shown  by  the  nature  of  the  pain  to  be  in  the  soft 


114  ORTHOPEDIC   SURGERY. 

parts, ^  which  is  circumscribed  or  localized,  so  to  speak,  in 
the  interior  region  of  the  articulation,  and  the  flexion  is 
due  to  the  permanent  retraction  of  the  muscles, —  when,  I 
say,  there  is  this  combination  of  circumstances,  and  the 
inflammation  has  resisted  all  common  therapeutic  means, 
I  believe  that  everything  may  be  expected  from  section  of 
the  retracted  muscles,  whatever  be  the  local  disorders  of  the 
articular  parts.  By  this  operation  we  shall  avoid  also  the 
chance  of  anchylosis  in  a  bad  position. 

"  Supported  by  numerous  facts,  I  believe  I  may  announce 
the  following  doctrine.  Pain,  inflammation,  alteration  of 
intra  and  extra-capsular  parts  or  of  the  integuments,  phleg- 
monous swelling,  oedema,  numerous  cicatrices,  suppurating 
surfaces,  —  all  these  circumstances,  which  seem  to  be  so 
many  contra-indications,  are  not  to  deter  the  operator,  but, 
on  the  contrary,  should  induce  him  to  act.  Prejudices 
which  might  have  previously  arrested  him  must  yield  to 
facts. "  2 

The  tendons  being  divided,  gradual  extension  is  applied 
to  the  limb. 

This  principle  is  based  upon  a  number  of  observations,  and 
is  supported  upon  the  ground  that  extension,  while  it  brings 
into  contact  new  and  less  diseased  parts  of  the  articulating 
surfaces,  separates  the  posterior  and  ulcerated  portions  from 
each  other,  and  by  relaxing  the  muscles  diminishes  the  pres- 
sure of  the  patella  upon  the  anterior  surface  of  the  femur. 
Extension  applied  before  section  of  the  retracted  flexor  mus- 
cles would  evidently  counteract  these  indications  by  bringing 
the  inflamed  surfaces  more  forcibly  together. 

M.  Guersent,  of  the  Hopital  des  Enfans,  asserts  that  in 
white  swelling  of  the  knee  it  is  almost  always  advantageous 

1  It  may  be  remarked  that  little  indication  of  the  seat  of  the  lesion 
can  be  drawn  from  the  character  of  the  pain. 

2  Duval,  p.  438. 


RICKETY   KNEES.  115 

to  practise  tenotomy  the  moment  circumstances  are  tolerably 
favorable  for  its  performance ;  that  is  to  say,  when  the  tumor 
is  not  extremely  painful,  and  the  inflammatory  symptoms 
begin  to  diminish  in  intensity.^ 

M.  Ribes,  a  French  writer  of  some  note,  expresses  himself 
as  follows :  "  Medical  art  is  rich  in  therapeutic  remedies  for 
the  relief  of  white  swelling  of  the  knee  joint,  but  in  almost 
all  cases,  from  an  obvious  cause,  they  have  proved  utterly 
inefficient.  This  cause  is  the  permanent  and  forced  con- 
traction of  the  flexor  muscles  of  the  leg.  Eh  Men  I  Why 
should  we  not  perform,  at  the  proper  time,  the  subcutaneous 
section  of  the  tendons  of  the  semi-membranosus,  semi-tendi- 
nosus,  and  biceps  muscles  which  provoke  this  uneasy  state 
of  things  ?  By  this  simple  operation  we  may  rationally 
hope  not  only  to  relieve  the  existing  pain  and  distress,  but 
also  very  materially  to  promote  the  formation  of  anchy- 
losis, and  consequently  the  cure  of  the  disease.  This  easy 
and  safe  operation  is  already  admitted  and  recognized  by 
surgeons. "  ^ 

It  is  unnecessary  to  say  that  great  caution  is  to  be  exer- 
cised in  accepting  evidence  of  this  sort,  and  especially  in 
experimenting  upon  a  lesion  sufficiently  grave  of  itself  to 
endanger  the  life  of  the  patient. 


RICKETY   KNEES. 

This  variety  of  distortion,  commonly  known  as  knock  knee 
and  hoiv  leg,  accompanies  in  many  cases  a  rickety  diathesis 
in  young  subjects.  It  results  in  part  from  the  flexibility  of 
the  bones.  In  the  former  variety  the  joint  also  becomes 
distorted,  either  from  the  relaxation  of  the  internal  ligament, 

1  Gazette  des  Ilopitaux,  4  Juillet,  1844. 

2  Medico-Chirurgical  Review,  October,  1844,  p.  469. 


116  ORTHOPEDIC   SUEGERY. 

or  the  arrest  of  development,  or  shortening  of  the  external 
lateral  ligament.  The  tibia  is  then  directed  obliquely  from 
above  downward  and  from  within  outward,  while  the  femur 
forms  another  side  of  a  triangle  of  which  the  summit  is  the 
knee.  The  articulating  surfaces  of  the  knee  joint  become 
oblique  in  the  line  of  a  perpendicular  projected  from  the 
summit  to  the  base  of  this  triangle.  The  extremities  of  the 
bones  are  often  enlarged. 

Medical  Treatment.  —  In  infants,  a  tonic  treatment  often 
suffices  to  rectify  completely  the  deviation,  especially  the 
outward  curvature.  The  following  suggestions  will  give  an 
idea  of  the  treatment  of  Guerin,  in  the  case  of  a  child  of  two 
or  three  years  of  age. 

Three  salt  water  baths  a  week,  with  the  addition  of  one 
pound  of  gelatine  to  each ;  friction  and  massage  morning  and 
evening;^  every  other  morning,  fasting,  a  table-spoonful  of 
syrup  of  gentian  alternating  with  cinchona.  For  habitual 
drink,  infusion  of  chicory  (slight  laxative  and  bitter)  with 
one  third  eau  de  Vichy  and  one  third  old  Bordeaux.  Light 
but  substantial  diet ;  fresh  eggs,  simple  soup ;  cooked  legu- 
minous vegetables  and  fruit,  but  neither  raw  fruit  nor  milk. 
Country  air.     No  walking  for  some  months. 

The  above  course  of  treatment  was  prescribed  by  M. 
Guerin  for  an  infant  of  two  and  a  half  years  of  age,  whose 
limbs,  previously  affected  with  the  outward  curvature,  be- 
came straight  at  the  expiration  of  a  few  months  after  its 
adoption,  A  simple  change  of  air  and  diet  often  produces 
the  same  effect.  ^ 

Surgical  Treatment.  —  When  the  child  has  attained  the 
age  of  six  or  eight  years,  the  firmness  of  the  external  lateral 

^  The  term  massage  may  be  rendered  in  English  by  the  word  sham- 
pooing. It  consists  of  friction  combined  with  pinching  and  kneading  of 
the  muscles,  and  with  the  gentle  alternate  extension  and  relaxation  of 
their  fibres. 

^  Writer's  notes  of  Guerin's  lectures. 


RICKETY    KNEES.  117 

ligament  in  the  inward  deviation  renders  it  expedient  to 
divide  it  rather  than  to  attempt  its  extension.  In  certain 
aggravated  cases  the  tendon  of  the  biceps  is  retracted, 
and  is  tlien  to  be  divided. 

M.  Guerin  does  not  hesitate  to  divide  the  external  lat- 
eral ligament,  thus  opening  the  articulation.  He  asserts 
that  no  ill  effect  results  from  this  operation,  (which  I 
have  often  seen  performed  by  him,)  provided  the  rules  for 
subcutaneous  perforation  of  the  articulations  are  strictly 
adhered  to. 

The  section  should  be  made  in  the  position  of  extension. 
M.  Guerin  has  endeavored  to  show  that,  in  certain  attitudes 
of  the  joints,  a  sort  of  vacuum  is  established  in  the  articu- 
lar capsules,  which  promotes  the  effusion  of  synovial  fluid 
from  the  secreting  surface  by  an  action  of  suction.  If  this 
be  established,  it  becomes  a  matter  of  importance  not  to 
divide  the  capsule  when  the  joint  is  in  such  a  position  as 
tends  to  draw  into  its  cavity  atmospheric  or  other  surround- 
ing fluids. 

Perfect  subsequent  rest  of  the  limb  should  be  enjoined. 

With  the  consecutive  and  long  continued  use  of  an  ap- 
paratus, as  M.  Guerin  affirms,  the  internal  portions  of  the 
oblique  articulating  surfaces  become  absorbed,  the  leg  re- 
gains a  perpendicular,  and  the  deformity  is  permanently 
relieved. 

Protracted  mechanical  treatment  is  required  to  produce 
the  essential  modification  in  the  joint.  Bonnet  states  that 
he  has  never  been  able  to  obtain  from  this  method  a  satis- 
factory result.  1 

1  Op.  cit.,  p.  575. 


118  ORTHOPEDIC  SURGERY. 


PERMANENT  FLEXION  OF  THE  HIP  JOINT. 

The  principles  of  treatment  of  false  anchylosis  of  the  knee 
by  gradual  extension  apply  equally  to  permanent  flexion  of 
the  hip.  It  is,  however,  more  difficult  to  appreciate  in  this 
lesion  the  amount  of  change  in  the  articular  structures.  The 
distortion  is  corrected  by  mechanical  force,  either  alone  or 
combined  with  the  section  of  tendons. 

A  year  or  two  after  the  cessation  of  active  inflammatory 
symptoms,  gradual  reduction  may  be  attempted  by  the  trac- 
tion of  a  weight,  spring,  or  other  mechanical  power.  If  the 
tendons  resist  the  effort,  the  tenotome  should  be  employed. 

The  tendons  which  have  been  divided  for  this  affection  are 
those  of  the  adductor  longus  and  magnus,  rectus  femoris, 
sartorius,  pectineus,  and,  lastly,  the  tendon  of  the  psoas  and 
iliacus.  The  two  last  muscles  have  been  divided  by  M. 
Guerin,  and  by  Dr.  Sargent  of  Worcester.  In  the  operation 
of  the  latter  surgeon  upon  a  boy  of  ten  years  of  age,  in  whom 
the  deformity,  of  three  years'  standing,  was  the  sequence  of 
apparent  cerebral  affection,  the  tenotome  was  introduced 
about  three  inches  below  the  anterior  superior  spinous  process 
of  the  ilium,  and  carried  in  a  direction  parallel  to  Poupart's 
ligament  up  to  the  edge  of  the  femoral  artery.  The  tendon 
being  extended,  the  knife  was  carried  to  the  bone,  when  the 
tension  yielded. 

Profuse  hemorrhage  followed  the  withdrawal  of  the  knife, 
only  arrested  by  compression  sufficient  to  produce  an  eschar 
two  inches  in  length.  But  the  patient,  who  before  the  opera- 
tion was  a  cripple,  confined  to  his  bed  or  walking  upon  his 
hands  and  knees,  recovered  in  a  great  measure  the  use  of 
his  limb,  and  now  walks  erect  without  a  cane. 
,  It  should  be  mentioned  that  the  puncture  was  first  made 


ANCHYLOSIS.  119 

at  a  point  about  one  inch  and  a  half  below  the  spinous 
process  of  the  ilium,  and  above  the  position  of  the  pro- 
funda and  recurrent  arteries,  which  would  have  then  es- 
caped division.  It  proved,  however,  that  the  cicatrices  of 
previous  sections  had  condensed  the  tissues  to  a  degree 
which  rendered  them  impenetrable  by  the  tenotome,  which 
was  therefore  reintroduced  lower  down.  The  crural  nerve 
was  divided.  The  proximity  of  the  tendon  of  the  psoas  to 
the  large  vessels  will  hinder  less  dexterous  surgeons  from 
attempting  its  division,  notwithstanding  the  eminently  sat- 
isfactory result  of  this  case.^ 

ANCHYLOSIS. 

Little  need  be  said  upon  this  subject.  It  is  rare  that  a 
case  of  simple  deformity  justifies  the  surgeon  in  hazarding 
the  life  of  the  patient  to  a  degree  which  the  operation  pro- 
posed for  anchylosis  demands.  The  integuments  and  soft 
parts  are  widely  incised,  and  the  bone,  after  being  exposed, 
is  sawed  apart.  The  patient  is  left  in  the  condition  of  a 
severe  compound  fracture. 

Dr.  J.  Rhea  Barton  first  performed  this  operation  upon  the 
hip  in  1827.2  The  neck  of  the  femur  was  divided,  and  a  ser- 
viceable joint  was  re-established ;  which,  however,  became 
again  anchylosed  at  the  end  of  six  years. 

A  similar  operation  was  performed  by  Dr.  Barton  in  May, 
1835,  upon  a  knee  anchylosed  at  an  angle.^  The  integu- 
ments were  divided,  and  a  wedge-shaped  mass  of  bone  was 
removed  from  the  femur  just  above  the  condyles,  the  base 
of  which  corresponded  with  the  anterior  surface  of  the  bone. 
The  limb  was  gradually  straightened,  the  bone  united,  and 
the  patient  was  enabled  to  walk  without  a  cane. 

1  New  England  Quarterly  Journal  of  Medicine  and  Surgery,  July,  1842. 

2  North  American  Medical  and  Surgical  Journal,  April,  1827. 
*  American  Journal  of  the  Medical  Sciences,  February,  1838. 


120  ORTHOPEDIC  SURGERY. 

The  first  of  these  operations  was  to  establish  a  joint,  the 
second  to  correct  the  deformity  of  the  limb. 

The  latter  operation  was  repeated  with  success  by  Professor 
Gibson  in  1841,i  and  the  former  by  Dr.  Rodgers^  in  1843, 
with  like  result. 

Dieffenbach  proposes,  in  his  last  treatise,  to  break  down 
the  osseous  union  of  the  knee  joint  with  an  instrument,  and 
Malgaigne  suggests  the  employment  of  a  chisel  and  mallet 
for  the  same  purpose. 


LATERAL   CURVATURE   OF  THE   SPINE. 

The  treatment  of  lateral  spinal  curvature  has  received 
much  attention  in  France,  and  has  recently  been  discussed 
at  length,  and  not  without  warmth,  in  the  Academy  of 
Medicine.  The  principal  advocates  of  the  opposite  modes 
of  treatment,  are   MM.   Guerin    and    Bouvier,^  the   one   in- 

1  American  Journal  of  the  Medical  Sciences,  July,  1842. 

2  Ibid.,  February,  184.3. 

3  The  following  are  the  conclusions  of  M.  Bouvier :  — 

That  the  section  of  the  sacro-lumbalis,  longissimus  dorsi,  spino-trans- 
verse  muscles,  etc.,  is  not  immediately  followed  by  diminution  of  spinal 
curvature. 

The  changes  which  the  curves  undergo  during  the  succeeding  mechani- 
cal treatment  are  exactly  identical  with  the  changes  produced  by  this 
treatment  alone,  when  it  has  not  been  preceded  by  the  section  of  the 
muscles. 

The  time  necessary  to  obtain  these  changes  is  the  same,  whether  we 
have  recourse  to  orthopedic  means  alone,  or  practise  also  section  of  the 
muscles. 

In  a  word,  dorso-lumbar  tenotomy  has  no  kind  of  influence  in  remedy- 
ing lateral  deviation  of  the  spine,  properly  so  called. 

M.  Bouvier  further  concludes  that  the  majority  of  lateral  curvatures 
of  the  spine  are  not  owing  to  muscular  contraction;  and  that  tlie  eti- 
ology of  the  distortion,  pathological  anatomy,  and  clinical  experiments 
proscribe  the  section  of  muscles  of  the  back  in  the  treatment  of  these 
curvatures. 


LATERAL  CURVATURE  OF   THE  SPINE.  121 

sisting  upon  the  necessity  of  muscular  section  in  certain 
cases  of  this  distortion,  the  other  maintaining  that  no 
advantage  is  to  be  derived  from  it. 

The  question  relates  to  the  duration  and  efficiency  of  the 
mechanical  treatment,  alone,  or  accompanied  with  section  of 
the  muscles,  and  can  only  be  satisfactorily  determined  by  the 
analysis  and  comparison  of  a  considerable  number  of  cases 
subjected  to  each  method.  The  operation,  being  attended 
with  little  pain  or  chance  of  subsequent  accident,  is  hardly 
to  be  taken  into  the  estimate  if  any  advantage  is  to  accrue 
from  it.  I  believe  M.  Guerin  has  shown,  as  far  as  he  is  able, 
that  the  treatment  is  abbreviated  in  certain  cases  by  the 
division  of  the  muscles.  If  it  is  established  that  these  tissues 
are  liable  to  undergo  the  fibrous  change  in  the  region  of  the 
spine  as  well  as  of  the  extremities,  as  is  undoubtedly  the  case, 
they  must  offer  a  certain  amount  of  resistance  to  any  attempt 
to  extend  them.  That  this  resistance  is  not  insurmountable, 
that  the  spinal  column  can  be  extended  in  spite  of  its  influ- 
ence, will  be  readily  conceded  by  those  who  have  seen  the 
tense  and  undivided  muscles  of  the  ham  slowly  yielding  to 
the  gradual  application  of  mechanical  force;  but  this  treat- 
ment is  often  accelerated  by  the  section  of  the  tendons  in  the 
popliteal  regions,  and  many  are  ready  to  admit  that  the  same 
advantage  is  to  be  obtained  by  the  division  of  the  tense  dorsal 
muscles  upon  the  concave  side  of  an  exaggerated  spinal  cur- 
vature. 

The  two  modes  of  treatment  need  further  investigation ; 
but  in  rejecting  the  exclusive  views  of  the  partisans  of  either 
method,  the  evidence  renders  it  highly  probable  that  the 
treatment  of  lateral  curvature  is  often  accelerated  by  dorsal 
myotomy.^ 

1  This  subject  has  been  revived  in  the  Academie  de  Me'decine  by 
1\I.  Malgaigne.  After  a  tedious  and  excited  discussion  upon  the  value  of 
dorsal  myotomy,  the  matter  was  referred  to  a  committee,  of  which  Roux 


122  ORTHOPEDIC   SURGERY. 

The  pathology  of  the  lesion  has  been  thoroughly  reviewed 
by  M.  Guerin,  whose  opportunities  have  enabled  him  also  to 
investigate  many  practical  considerations  connected  with  the 
treatment. 

The  following  is  a  brief  exposition  of  the  views  of  M.  Guerin, 
with  such  additions  as  embrace  the  more  important  sugges- 
tions of  other  writers. 

CAUSES. 

A  lateral  deviation  of  the  spine  presents  certain  alterations 
in  the  conformation,  structure,  and  relative  position  of  the 
vertebral  column  and  surrounding  tissues.  The  advanced 
age  of  the  patient,  the  long  duration  or  the  exaggerated 
degree  of  this  distortion,  are  conditions  which  give  rise  to 
secondary  alterations,  and  place  such  deviations  beyond  the 
reach  of  art. 

and  Velpeau  were  members.  The  report  of  this  committee  was  read  to 
the  Academy,  November  12,  1844 ;  and  may  be  considered  as  embodying 
all  that  is  yet  settled  upon  this  point.  The  following  are  extracts  from 
this  report :  — 

"  Although  it  should  be  proved  that  tenotomy  was  unavailing  in  the 
cases  cited  by  M.  Malgaigne,  we  should  have  no  right  to  declare,  for  that 
reason,  that  the  operation  was  never  efficacious." 

"We  do  not  admit  that  spinal  curvatures  are  unaccompanied  with 
muscular  contraction  in  all  subjects." 

"  But  it  is  important  not  to  deceive  ourselves  upon  the  value  of  tenot- 
omy in  such  cases;  nor  yet  to  decide  upon  it  unless  we  can  establish 
materially  the  existence  of  unyielding  or  tense  cords  upon  the  concave 
side  of  the  deviation,  not  merely  under  the  influence  of  certain  active 
positions,  but  when  we  try  to  straighten  the  curve  by  externally  applied 
force." 

And  among  the  conclusions  :  — 

"  Nothing  at  present  justifies  the  opinion  of  those  who  attribute  the 
majority  of  lateral  curvatures  of  the  spine  to  convulsive  or  active  retrac- 
tion of  the  muscular  system. 

"  But  the  secondary  shortening  of  certain  muscles  in  the  concavity  of 
the  curves  ought  to  hinder  us  from  rejecting,  a  priori  and  absolutely, 
spinal  myotomy." 

The  question  thus  stands  much  as  it  did  before. 


LATERAL  CURVATURE   OF  THE  SPINE.  123 

Tuberculous  and  other  disease  of  the  bones,  anchylosis,  and 
osseous  transformation  of  the  fibrous  structures,  are  also  con- 
ditions foreign  to  the  class  of  cases  about  to  be  described. 

Certain  forms  are  eminently  adapted  to  receive  aid  from 
an  operation,  —  greater  in  proportion  to  the  youth  of  the 
patient  and  the  inconsiderable  degree  of  distortion.  In  such 
cases,  the  muscles  which  form  the  chord  of  the  principal 
curvature  are  either  primitively  or  consecutively  contracted, 
and  display  themselves  in  certain  positions  of  the  body  in  the 
form  of  a  resisting  fasciculus,  which  hinders  the  vertebral 
column  from  assuming  a  normal  position.  This  muscular 
retraction  is  identical  with  that  of  club-foot  and  wry-neck. 

As  a  primitive  lesion,  and  a  cause  of  osseous  distortion, 
lateral  deviation  is  congenital  or  yion-congenital. 

CAUSE  OF  THE  CONGENITAL  VARIETY. 

That  the  congenital  variety  is  due,  like  other  congenital 
deformity,  to  muscular  spasm,  resulting  from  nervous  in- 
fluence, is  shown, — 

1.  By  the  frequency  with  which  deviations  of  the  spine 
and  other  articular  deformities,  such  as  exaggerated  distor- 
tion of  the  superior  and  inferior  limbs  at  their  different  joints, 
and  also  of  the  hands,  feet,  etc.,  coexist  in  fcetal  monstrosi- 
ties, which  offer  evident  alteration  of  the  brain  and  spinal 
marrow.  These  cases  present  marked  muscular  traction  in 
the  direction  of  each  deformity,  proportioned  in  degree  to  the 
intensity  of  the  lesions  of  the  nervous  centres. 

2.  By  congenital  deviations  of  the  vertebral  column  ob- 
served in  the  living  subject,  and  accompanied  either  with 
strabismus,  club-foot,  torticollis,  or  other  distortion  of  the 
skeleton,  or  with  appearances  of  convulsions  in  the  face, 
irregularity  of  the  two  halves  of  the  cranium,  or  diminution 
of  force  and  even  paralysis  in  certain  parts  of  the  muscular 
system;  or,  finally,  with  veritable  congenital  spasmodic  affec- 


124  ORTHOPEDIC  SURGERY. 

tions,  such  as  epilepsy,  hemiplegia,  paraplegia,  with  or  with- 
out muscular  contraction. 

In  the  non-congenital  form,  it  is  equally  shown  by  cases  of 
spinal  deviation,  dating  from  a  period  subsequent  to  birth  and 
immediately  following  cerebral  or  cerebro-spinal  affections. 

It  is  accompanied,  as  in  the  preceding  form,  with  a  great 
number  of  other  deformities,  such  as  strabismus,  torticol- 
lis, club-foot,  deviations  of  the  knee,  all  dating  from  mus- 
cular convulsions,  and  accompanied  with  retraction  of  the 
muscles  exactly  in  relation  with  the  form  and  degree  of  these 
deformities. 

In  these  two  varieties,  the  essential  characters  of  the  dis- 
ease are  the  same,  and  identical  with  those  in  which  the 
deviation  alone  remains  to  indicate  the  existence  of  a  similar 
cause  at  some  previous  period. 

MUSCULAR   RETRACTION, 

Muscles.  —  The  anatomical  characters  of  the  retracted  tis- 
sues accompanying  spinal  deviation  are  the  same  as  those  of 
retracted  muscles  in  other  regions. 

At  first,  in  a  state  of  spasmodic  contraction,  they  become 
in  a  measure  paralyzed,  their  development  is  arrested,  and 
degeneration  commences ;  fibrous,  if  they  are  submitted  to 
traction ;  fatty,  if  they  remain  in  a  state  of  repose. 

The  condition  of  active  contraction  differs  from  that  of 
passive  retraction.  In  the  former,  the  muscle  is  tense,  acts 
as  the  immediate  cause  of  the  vertebral  curve,  and  limits  its 
extent.  In  the  latter  condition,  it  merely  accommodates  it- 
self to  the  distance  between  the  extremities  of  the  curve,  and 
is  less  forcibly  extended. 

In  both  cases  the  shortened  tissue  is  moderately  resisting. 
In  the  former  or  fibrous  change,  the  tissues  are  felt  beneath 
the  skin,  as  a  hard,  fasciculated  mass,  occasionally  giving  the 
sensation  of  fibro-cartilage  if  the  spinal  column  be  extended. 


LATERAL  CURVATURE  OF  THE  SPINE.  125 

The  muscle  is  found  to  be  diminished  in  size,  retracted,  paler, 
of  a  whitish  yellow,  of  an  eminently  fibrous  or  fibro-fatty  tex- 
ture, contrasting  strongly  with  the  regular  form,  red  color, 
and  fleshy  consistence  of  the  corresponding  normal  muscles. 
The  longissimus  dorsi  is  occasionally  so  fibrous  that  its  apo- 
neurotic and  tendinous  portion  acquires  a  double  length  at 
the  expense  of  the  muscular  portion. 

In  the  fatty  degeneration,  the  muscle  becomes  somewhat 
softer  than  natural,  and  retains  its  original  volume. 

After  the  section  of  muscles  thus  retracted,  the  extremi- 
ties reunite  by  means  of  an  intervening  portion,  of  adequate 
length  ;  this  tissue  regains  its  normal  character,  and  becomes, 
in  a  word,  muscle. 

Vertebrae.  —  Upon  the  convexity  of  the  curvature,  both  the 
vertebrae  and  their  intervening  fibro-cartilages  increase  in 
thickness,  while  the  concavity  is  marked  by  a  corresponding 
absorption  and  diminution  of  substance  of  the  same  parts. 
They  thus  acquire  individually  a  wedge  shape. 

Ligaments.  —  In  cases  of  long  standing  or  of  great  de- 
viation, the  ligaments  may  become  retracted,  and  even  ossi- 
fied, in  consequence  of  which  the  vertebrae  tend  to  become 
anchylosed. 

Thorax.  —  The  ribs  follow  the  deviation  of  the  spine,  and 
in  exaggerated  examples  the  thoracic  cavity  is  distorted  and 
compressed,  and  the  contained  viscera  are  modified  in  position, 
form,  and  structure.  Portions  of  the  lungs  may  become  in- 
durated, and  even  acquire  a  fibro-cellular  structure.^ 

The  progress  of  this  sort  of  deviation  is  chiefly  due  to 
mechanical  causes.  The  column  once  bent  is  powerfully 
acted  upon  by  the  weight  of  the  body  in  a  vertical  position, 
to  a  degree  which  slackens  the  extended  cords,  and  renders 
it  difficult  to  detect  them  beneath  the  skin.  They  are  not  for 
this  reason  less  efficient  in  retaining  the  spine  in  its  abnormal 

1  Difformites  du  Systeme  Osseux,  p.  26. 


126  ORTHOPEDIC  SURGERY. 

position ;  and  an  upright  posture  commonly  restores  their 
tenseness  and  indicates  their  locality.  In  a  young  and  recent 
subject  this  tenseness  may  be  made  apparent  by  suspending 
the  body  by  the  head. 

The  retraction  is  sometimes  considerable,  amounting  to  a 
third  of  the  length  of  the  muscle,  and  is  always  proportioned 
to  the  curvature.  In  some  cases  the  muscles  situated  on  the 
convex  side  of  a  curvature  slip  over  the  spinous  processes  to 
occupy  a  position  upon  its  concavity. 

CAUSES   OP   THE    NON-CONGENITAL   VARIETY. 

Among  the  causes  of  the  non-congenital  form  of  spinal 
deviation  are :  —  1.  The  convulsions  of  infancy.  2.  Local  or 
general  spasmodic  action  occurring  at  a  later  period  of  life. 

These  causes,  recognized  as  producing  distortion  of  the 
limbs  and  neck,  have  also  their  influence  upon  the  muscles 
of  the  vertebral  column,  which  is  thus  suddenly  curved, 
though  the  resistance  of  its  surrounding  tissues  may  render 
the  deviation  so  inconsiderable  as  to  prevent  its  immediate 
detection.  Wounds  of  the  muscles  of  the  back,  and  blows  or 
other  violence  to  these  tissues,  may  be  an  immediate  cause 
of  their  permanent  contraction. 

Other  causes  are  a  want  of  general  muscular  and  ligamen- 
tous force ;  an  inequality  in  the  antagonizing  power  of  oppos- 
ing muscles,  or  the  paralysis  of  some  of  them ;  an  abnormal 
inclination  of  the  plane  of  support ;  an  original  inequality  of 
the  two  halves  of  the  skeleton ;  rickety  or  scrofulous  tenden- 
cies ;  any  of  which  suffice  either  to  create  a  deviation,  or  to 
occasion  a  predisposition  to  curvature,  which  the  co-operation 
of  slight  causes  develops.  The  superincumbent  weight  of  the 
body,  and  the  tendency  of  the  muscles  to  accommodate  their 
length  to  the  distance  between  the  approaching  extremities 
of  the  arc,  augment  the  curve  in  proportion  to  their  force, 
and  the  inability  of  the  parts  to  resist  their  influence. 


LATERAL   CURVATURE   OF  THE   SPINE.  127 

CURVATURE   AND   TORSION. 

A  lateral  deviation  of  the  spine  consists  of  two  elements, 
to  be  separately  considered,  curvature  and  torsion. 

Curvature  is  of  two  kinds.  The  one  occupies  the  imme- 
diate seat  of  the  lesion ;  the  other  is  an  accompanying  and 
compensating  deviation.  The  trunk  always  tends  to  main- 
tain an  upright  position.  As  soon  as  a  part  of  the  vertebral 
column  deviates  from  a  perpendicular,  another  portion  insti- 
tutes a  curve  in  an  opposite  direction  by  way  of  restoring  to 
the  mass  its  centre  of  gravity.  For  this  reason,  a  single 
curve  never  exists  alone.  It  is  rare  that  two  are  found 
unaccompanied  by  a  third.  Three  are  very  common,  and 
four  are  occasionally  met  with. 

The  position  of  the  spinous  processes  is  not  in  all  cases  an 
indication  of  the  extent  or  direction  of  the  deviation.  In  a 
pathological  specimen  exhibited  to  the  Academy  of  Medi- 
cine, the  column  viewed  from  behind  offered  a  single  curve, 
while  the  bodies  of  the  vertebrae  in  front  presented  four 
curves.  This  apparent  anomaly  is  due  to  torsion,  which 
accompanies  all  cases  of  deviation. 

The  principle  of  torsion  is  illustrated  by  an  attempt  to 
bend  a  blade  of  grass,  or  a  flat  flexible  stick,  in  the  direc- 
tion of  its  width.  The  centre  immediately  rotates  upon  its 
longitudinal  axis  to  bend  flatwise  in  the  direction  of  its 
thickness.  In  the  same  way,  the  spine  laterally  flexed 
turns  upon  its  vertical  axis  to  yield  in  its  shortest  or  antero- 
posterior diameter. 

The  centre  of  rotation  or  torsion  is  a  vertical  line  through 
the  summits  of  the  spinous  processes,  which  remain,  in  con- 
sequence, comparatively  stationary,  while  the  bodies  of  the 
vertebrae  rotating  around  this  centre  tend  to  occupy  the 
outside  of  the  convexity.  For  this  reason  it  often  happens 
that  the  principal  curve  alone  can  be  detected  by  the  direc- 


128  ORTHOPEDIC  SURGERY. 

tion  of  its  spinous  processes,  and  writers  have  been  thus  led 
to  admit  the  existence  of  single  curvature. 

Each  vertebra  of  a  curve  is  laterally  bent  upon  its  antero- 
posterior axis,  and  the  spinous  processes  are  thus  inclined 
towards  the  transverse  processes,  upon  the  convexity  of  the 
deviation.  The  vertebrae  at  the  point  of  transition  from  one 
curve  to  another  are  alone  to  be  excepted  from  this  rule. 

Other  elements  of  the  mechanism  of  torsion  are :  — 

1.  The  disposition  of  the  articulating  surfaces,  which,  in 
the  cervical  and  dorsal  regions,  are  oblique,  while  in  the 
lumbar  region  they  are  nearly  transverse. 

2.  The  resistance  of  the  lateral  muscles,  which  become 
subsequently  retracted.  Among  the  principal  are  the  costal 
insertions  of  the  longissimus  dorsi,  the  inter-spinales,  and 
the  inter-transversales  muscles  and  ligaments,  which  fix  the 
summits  of  the  processes,  while  the  bodies  of  the  vertebrae 
yield  to  the  effort  of  flexion. 

GIBBOSITY. 

To  the  action  of  torsion  is  due  the  prominence  of  the  ribs, 
muscles,  scapula,  and  shoulder  upon  the  convex  side  of  the 
curve,  and  the  corresponding  depression  upon  the  concavity. 
This  deformity,  commonly  termed  "gibbosity,"  is  constant 
in  cases  of  pathological  deviation. 

CURVES. — THEIR   POSITION    AND    MECHANISM. 

It  is  rare  to  find  two  vertebral  columns,  pathologically 
distorted,  which  offer  precisely  the  same  characters.  Never- 
theless certain  curves  are  more  frequent  than  others.  A 
convexity  to  the  right  above,  and  to  the  left  below,  is  more 
common  than  the  reverse. 

The  principal  curve  commonly  occupies  the  dorsal,  or 
dorso-lumbar  region;  a  circumstance  explained  by  the  fact 
that  the  centre  of  the  movements  of  totality,  of  the  vertebral 


LATERAL  CURVATURE  OF  THE  SPINE.  129 

column,  and  of  lateral  flexion  in  particular,  is  situated  at 
the  point  of  junction  of  the  dorsal  and  lumbar  regions.  This 
is  due  to  the  following  anatomical  disposition  of  the  articu- 
lation, uniting  the  eleventh  and  twelfth  dorsal  vertebras. 

"The  articulating  facets  are  more  perpendicular  and 
transverse. 

"  A  sort  of  notch  is  formed  by  a  prolongation  upward  and 
forward  of  the  superior  tubercle  of  the  transverse  process  of 
the  twelfth  dorsal  vertebra,  which  is  recurved  like  a  hook, 
so  as  to  convert  into  a  transverse  groove  the  space  comprised 
between  this  appendix  and  the  superior  articulating  process 
of  the  same  vertebra.  In  this  groove  is  received  the  inferior 
edge  of  the  articulating  facet  of  the  eleventh  dorsal  ver- 
tebra, which  slides  there  without  the  least  obstacle  during 
the  movements  of  lateral  flexion  of  the  column.  Besides 
this  circumstance,  certain  muscles,  the  quadrati-lumborum, 
the  common  mass  of  the  sacro-lumbalis,  longissimus  dorsi, 
and  semi-spinales,  which  are  the  agents  of  lateral  flexion, 
are  to  a  certain  extent  circumscribed  in  this  region,  and 
belong  especially  to  it." 

A  similar  conformation,  but  less  marked,  exists  in  the 
neighboring  dorsal  vertebrae,  which  gradually  lose  this  pecu- 
liarity in  receding  from  this  point,  so  that  the  natural  curve 
in  the  lateral  movements  of  the  spine  decreases  from  the 
loins  upward. 

A  single  principal  deviation  once  established,  curves  of 
compensation  immediately  follow,  as  the  result  of  subse- 
quent active  muscular  contraction,  and  the  trunk  is  restored 
to  a  perpendicular. 

These  secondary  curves  are  sometimes  hardly  appreciable. 
That  occupying  the  cervical  region  is  often  slight,  and  when 
masked  by  the  action  of  torsion  is  sometimes  not  indicated 
by  a  corresponding  curve  of  the  spinous  processes.  As  was 
before  remarked,  an  existing  alternate  deviation  of  the  bodies 

9 


130  ORTHOPEDIC   SURGERY. 

of  the  vertebra)  of  the  entire  column  sometimes  presents  no 
appreciable  variation  from  a  perpendicular  when  viewed 
from  behind. 

A  dorso-lumbar  deviation  is  always  arrested  in  the  dorsal 
region  to  give  place  to  a  curve  of  compensation.  Though 
more  frequent  at  the  junction  of  the  lumbar  and  dorsal  ver- 
tebrae, the  distortion  may  occupy  any  portion  of  the  vertebral 
column,  and  is  attended  with  a  general  prominence  of  the 
parts  upon  its  convexity,  and  a  corresponding  depression  in 
its  concavity. 

Exaggerated  deviation  is  accompanied  by  wrinkles  of  the 
skin,  corresponding  to  the  concave  side  of  the  most  consid- 
erable curve,  often  a  short  distance  below  the  axilla. 

The  trunk,  supported  by  alternate  curves,  is  very  slightly 
or  not  at  all  inclined ;  the  hip  is  never  elevated,  it  the  legs 
be  of  equal  length,  nor  does  the  subject  necessarily  walk 
lame. 

The  muscles  which  are  commonly  retracted  in  the  princi- 
pal or  dorso-lumbar  curvature  are  the  common  mass  of  the 
sacro-lumbalis  and  longissimus  dorsi ;  in  the  central  dorsal 
region,  the  same  mass,  with  the  spinalis  and  semi-spinalis 
dorsi;  at  the  cervico-dorsal  curve,  the  complexus,  cervicalis 
ascendens  and  transversalis  colli. 

The  lesion  may  occupy  other  positions.  Certain  portions 
of  the  trapezius  may  be  retracted  and  fibrous  by  the  side  of 
other  portions  paralyzed,  atrophied,  and  membranous,  and 
even  by  the  side  of  healthy  muscle.  All  the  muscles  of  the 
back  are  sometimes  retracted,  producing  great  distortion. 
The  long  dorsal  may  be  alone  retracted  by  the  side  of  the 
sacro-lumbalis  passively  affected,  or  a  simple  fasciculus  of 
one  of  these  muscles  may  offer  a  state  of  tension  in  the 
midst  of  healthy  tissues.  In  such  cases  it  is  amply  proved 
that  the  extended  muscular  bands,  when  subjected  to  torsion, 
may  become  retracted ;  in  other  words,  their  development  is 


LATERAL   CURVATURE   OF  THE   SPINE.  131 

arrested ;  they  are  in  a  measure  paralyzed,  and  more  or  less 
transformed  into  fibrous  tissue.  In  such  conditions  they 
fulfil,  with  regard  to  the  spine,  the  functions  of  a  string  in 
a  bent  bow. 

TREATMENT. 

Distortion  of  the  spine  is  less  amenable  to  treatment  than 
other  deformity ;  chiefly,  perhaps,  from  the  difficulty  of  ap- 
plying to  it  a  permanent  and  properly  directed  mechanical 
force.  A  first  difficulty  presents  itself  in  the  necessity  of 
flexing  the  entire  body,  in  order  to  affect  corresponding  flex- 
ion of  the  vertebrae.  The  trunk  is  unwieldy,  and  a  lateral 
force  can  be  applied  only  through  the  intervention  of  the 
ribs,  shoulders,  or  pelvis.  Nor  can  it  be  maintained  for  a 
length  of  time.  The  respiration  is  impeded,  the  posture  is 
constrained,  the  integuments  are  irritable,  and  the  subject 
impatient  of  confinement.  The  mechanical  treatment  must 
therefore  be  frequently  suspended,  and  in  these  intervals 
various  influences,  among  which  the  vertical  weight  of  the 
trunk  is  not  the  least,  tend  to  reproduce  the  deformity.  The 
subsequent  exercise  of  the  muscles,  so  important  in  ortho- 
pedic treatment,  can  only  be  accomplished  in  the  region  of 
the  spine  by  exaggerated  and  comparatively  fatiguing  move- 
ments of  the  whole  body. 

It  is  obvious  that  such  conditions  are  far  less  promising 
than  those  which  commonly  attend  the  treatment  of  club-foot, 
where  the  whole  distortion  is  embraced  by  the  apparatus, 
which  maintains  an  unremitting  and  progressive  force  as 
long  as  it  may  be  required,  and  where  the  gentle  exercise  of 
walking  subsequently  secures  the  advantage  obtained  from 
the  use  of  a  machine. 

The  results  of  the  treatment  of  spinal  curvatures  are,  as 
might  be  expected,  much  less  satisfactory  than  those  of  most 
other  distortions,  while  the  time  required  is  longer;   and 


132  ORTHOPEDIC  SURGERY. 

hence  the  difficulty  of  deciding  between  the  claims  of  different 
methods. 

The  deformity  is  often  inconsiderable  and  stationary,  and 
requires  no  treatment. 

At  other  times  the  constitution  of  the  patient  requires  to 
be  fortified  by  change  of  air,  food,  salt  baths,  cold  douche, 
frictions,  and  massage.  Exercise  in  the  open  air  is  im- 
portant, and  the  mechanical  treatment  of  this  deformity  is 
always  combined  with  gymnastic  exercises.  These  should 
be  so  contrived  as  to  strengthen  the  muscles  upon  the  con- 
vexity of  the  principal  curve,  and  to  elongate  those  upon 
its  concavity.  Such  are  climbing  the  under  side  of  a  spiral 
ladder,  turning  a  crank  above  the  head  and  on  the  side  of 
the  concavity  in  a  horizontal  position,  a  lateral  rocking-horse 
inclined  towards  the  side  of  the  concavity.  These  will  serve 
as  examples  of  a  great  variety  of  contrivances  obvious  to  a 
mechanician. 

A  bag  of  sand  or  shot,  carried  upon  the  head  while  the 
patient  walks,  is  an  excellent  method  of  exercising  the  dor- 
sal muscles.^  But  when  the  patient  is  at  rest,  its  vertical 
weight  would  obviously  tend  to  exaggerate  the  curvatures. 

If,  however,  in  certain  postures  of  the  patient,  a  tense 
fasciculus  appears  beneath  the  skin  upon  the  concave  side 
of  the  principal  curvature  in  the  position  of  a  chord  uniting 
the  two  extremities  of  the  arc,  there  is  little  doubt  that  the 
progress  of  mechanical  treatment  will  be  accelerated  by  its 
subcutaneous  division.  Even  were  the  section  of  muscles 
unnecessary,  the  operation  is  attended  with  no  danger  and 
with  little  pain  or  hemorrhage.  It  offers  no  impediment 
to  subsequent  mechanical  treatment,  which  is  the  same  in 
every  respect  except  in  its  duration,  whether  the  muscles  be 
severed  or  not. 

1  The  straight  backs  of  negroes,  and  of  people  accustomed  to  carry 
weights  upon  their  head,  are  proverbial. 


LATERAL   CURVATURE   OF   THE   SPINE.  133 


SURGICAL  TREATMENT. 

In  a  case  such  as  that  just  mentioned  the  exact  position  of 
the  retracted  fasciculus  is  ascertained  by  placing  the  patient 
in  a  vertical  or  horizontal  position,  or  by  making  extension, 
if  requisite.  Parallel  extension  is  sometimes  used  to  effect 
an  elongation  of  the  muscles  preparatory  to  their  section. 

OPERATION. 

M.  Guerin  nowhere  indicates  the  manual  of  the  operation. 
In  those  I  have  seen  performed  by  him,  amounting  to  a  dozen 
or  more,  the  patient  was  laid  upon  his  belly  upon  the  table. 
The  hands  being  extended  by  the  side,  the  patient  was  desired 
to  raise  his  head,  an  action  by  which  the  dorsal  muscles  were 
brought  into  play  and  their  retracted  fibres  made  tense.  A 
fold  of  skin  was  then  pinched  up  at  the  outer  edge  of  the  ex- 
tended fasciculus,  and,  a  puncture  being  made,  the  myotome 
was  introduced  flatwise  at  the  base  of  the  fold,  at  a  point 
which  afterward  receded  to  the  distance  of  an  inch  from 
the  external  border  of  the  muscle.  The  knife  being  then 
turned  upon  the  mass,  the  fibres  were  divided  by  a  sawing 
motion  communicated  to  the  convex  edge  of  the  blade. 

By  reason  of  its  fibrous  character,  the  resisting  cord  is 
divided  with  precision  and  at  once ;  and  its  complete  sec- 
tion is  attended  with  a  sharp  and  distinct  snap,  as  the 
extremities  recede  one  from  another.  On  the  other  hand, 
non-retracted  muscular  fibres  are  soft,  and  yield  before  the 
instrument,  which  is  unable  to  effect  either  a  clean  or  a 
rapid  division  of  their  substance. 

Immediately  after  the  operation,  certain  elements  of  the 
deformity  disappear  at  once,  and  other  fibres  rise  to  take 
the  place  of  those  which  have  been  severed.  They  often  oc- 
cupy nearly  the  same  position,  and  their  section  is  attended 
with  an  additional  correction  of  the  deviation. 


134  ORTHOPEDIC  SURGERY. 

A  similar  occurrence  sometimes  takes  place  at  the  end  of 
six  or  eight  months  after  the  commencement  of  mechanical 
treatment.  When  the  curvature  remains  undiminished  dur- 
ing several  months,  the  redivision  of  the  muscles  is  attended 
with  a  new  diminution  of  the  curve,— generally  rapid  dur- 
ing the  first  days  following  the  operation. 

MECHANICAL    TREATMENT. 

Mechanical  treatment  is  effected  either  by  portable  appar- 
atus, which  allows  the  patient  to  move  about,  or  by  mechan- 
ical beds,  in  which  force  is  applied  horizontally. 

In  the  former,  a  broad  metallic  belt  embraces  the  hips, 
and  serves  as  a  fixed  point,  from  which  extension  is  applied 
either  to  the  head  or  more  commonly  to  the  shoulders.  The 
inconvenience  of  the  latter  method  is  apparent.  The  shoul- 
ders and  scapula  yield  to  the  force,  while  the  vertebral 
column  is  unaffected  by  it. 

The  Apparatus  of  Hossard,  modified  by  Tavernier,  does  not 
aim  at  extension.  It  consists  of  a  belt  of  wadded  leather, 
four  or  five  inches  broad,  and  fixed  around  the  pelvis  by 
horizontal  and  perineal  straps.  Behind,  a  steel  upright 
reaches  to  the  height  of  the  shoulders,  and  is  attached  to  the 
belt  by  ratchet-work,  which  admits  of  its  lateral  inclination 
towards  the  shoulder  of  the  concave  side  of  the  curve. 
From  its  summit  a  broad  strap  winds  spirally  downward 
round  the  convexity  of  the  curve,  which  it  presses  towards  a 
perpendicular,  and  is  fixed  to  the  belt  in  front.  The  trunk, 
being  thus  thrust  from  its  centre  of  gravity,  tends  in  recover- 
ing itself  to  correct  the  spinal  deviation. 

The  strap  should  traverse  the  most  salient  point  of  the  ribs 
behind,  while  a  second  strap  passes,  if  required,  in  the 
contrary  direction  around  the  lumbar  curve.  This  efficient 
apparatus  does  not  forbid  active  exercise.  Its  great  advan- 
tage is,  that  the  correcting  force  is  purely  muscular,  and 


LATERAL   CURVATURE   OF   THE   SPINE.  135 

derived  from  the  efforts  of  the  body  to  regain  the  perpendic- 
ular from  which  it  is  thrust  by  the  machine.  Shoulder 
supports,  and  the  "  Minerva  "  already  described  ^  which  exer- 
cises traction  upon  the  head,  being  substitutes  for  muscular 
action,  only  enfeeble  this  function  in  their  effort  to  supply 
its  place. 

Marshall  Hall  proposes  to  take  a  plaster  cast  of  the  body, 
in  an  upright  position,  and  to  deposit  upon  it  by  the  galvano- 
plastic  method  a  coating  of  copper.  The  whole  is  sawed  in 
two  vertically,  and  a  pair  of  copper  corsets  are  thus  pro- 
duced exactly  fitted  to  the  trunk. ^  The  idea  is  ingenious, 
but  the  principle  of  support  is  open  to  the  objection  just 
mentioned. 

Various  orthopedic  beds  have  been  devised  for  the  purpose 
of  effecting  horizontal  extension.  In  these  the  force  is  best 
applied  in  a  direction  parallel  to  that  of  the  spine,  or  in  a 
direction  perpendicular  to  it. 

PARALLEL   EXTENSION. 

Parallel  Extension  is  effected  by  fixing  the  pelvis  and 
applying  an  extending  power  to  a  series  of  straps  passed 
round  the  chin  and  head.  This  is  best  effected  by  a  ma- 
chine about  to  be  described. 

The  method  of  parallel  extension  is  applicable  in  old  and 
very  pronounced  curvatures,  where  the  extent  of  the  curve 
gives  power  or  purchase  to  simple  traction.  Also  in  the 
deviations  with  four  curves,  or  where  one  closely  follows 
another  in  the  dorsal  region.  It  is  then  impossible  to  apply 
perpendicular  force  to  each  curve  separately,  on  account  of 
their  proximity.  Continued  force  of  this  sort  is  liable  to 
produce  a  relaxation  of  the  ligaments,  which  predisposes 
the  spine  to  a  recurrence  of  the  deformity.  It  also  tends 
to  efface  the  natural  antero-posterior  curves.     Many  young 

1  See  page  95,  and  Fig.  24.  -  Laucet,  February  3,  1844. 


136  ORTHOPEDIC  SURGERY. 

people  treated  in  establishments  where  orthopedic  beds  are 
exclusively  employed,  have  their  backs  flattened,  the  shoul- 
ders and  other  regions  of  the  vertebral  column  being  reduced 
to  the  same  plane.  These  ill  effects  are  to  be  combated 
by  suitable  gymnastic  exercise  alternating  with  extension. 
Horizontal  extension  also  acts  but  indirectly  upon  the  wedge- 
shaped  conformation  of  the  vertebrae,  its  power  diminishing 
as  the  curve  becomes  less  marked. 

SIGMOID    EXTENSION. 

The  method  which  Guerin  has  called  sigmoid  extension  con- 
sists of  several  elements. 

The  first  of  these  is  parallel  extension,  the  head  and  pelvis 
being  respectively  attached  to  the  top  and  bottom  of  the  bed. 

The  second  is  a  lateral  force  applied  to  a  point  upon  the 
side  of  the  trunk  corresponding  to  the  convexity  of  the 
curve,  and  in  a  direction  perpendicular  to  it.  The  action  is 
analogous  to  that  of  straightening  a  bow,  when  the  extremi- 
ties are  held  in  the  hands,  and  the  knee  is  applied  at  an 
intermediate  point  of  the  convexity.  It  has  several  advan- 
tages over  ordinary  parallel  extension.  The  power  is  applied 
to  greater  advantage,  and  a  temporary  curve  in  the  opposite 
direction  is  substituted  for  the  original  curve,  as  in  the 
attempt  to  straighten  a  bow. 

This  feature  of  sigmoid  extension  is  of  great  importance. 
To  effect  it,  two  uprights  are  placed  upon  opposite  sides  of 
the  bed,  one  above  the  other,  at  points  which  correspond 
with  the  convexity  of  each  curve,  and  are  capable  of  being 
advanced  towards  a  median  line  and  fixed  in  that  position. 
This  simultaneous  application  of  the  power  to  the  extremities 
and  convexity  of  the  double  curve,  or  S,  suggested  the  term 
sigmoid  extension.  It  is  the  more  efficient,  as  many  devia- 
tions have  their  principal  curve  at  the  level  of  the  dorso- 
lumbar  region,   which  answers   to   the  articulation  already 


LATERAL  CURVATURE  OF  THE  SPINE.  137 

described  of  the  eleventh  and  twelfth  dorsal  vertebra?  a 
coincidence  which  greatly  aids  the  action  of  the  machine. 

A  third  peculiarity  is  the  combination  of  flexion  and 
extension.  It  is  effected  by  placing  the  centres  of  rotation 
of  the  upper  and  lower  portions  of  the  bed  upon  opposite 
sides.  In  illustration  of  this,  provide  a  strip  of  board  and  a 
pair  of  compasses,  the  length  of  which  is  equal  to  the  width 
of  the  board.  Saw  the  board  across,  and  placing  the  shut 
compasses  horizontally  in  the  interval  of  division,  attach  a 
leg  to  each  of  the  sawed  surfaces.  The  joint  of  the  com- 
passes forms  a  lateral  centre  of  rotation  for  the  boards,  and, 
in  flexing  one  board  upon  the  other,  the  triangular  interval 
of  separation  gradually  increases.  If  the  board  be  again 
sawed  and  provided  with  a  similar  joint  upon  the  opposite 
side,  this  arrangement  will  represent  the  orthopedic  bed 
employed  by  M.  Guerin,  in  which  a  joint  corresponds  to  each 
of  the  two  principal  curves.  The  body  of  the  patient  fixed 
upon  it  is  at  once  flexed  by  the  joints,  and  extended  by  the 
increasing  intervals  of  separation. 

A  helmet  is  united  to  the  apparatus  by  a  universal  joint, 
and  serves  for  the  mechanical  treatment  of  torticollis.  It  is 
capable  of  being  fixed  in  any  position  which  the  cervical 
vertebrae  in  their  normal  state  are  capable  of  assuming,  and 
acts  as  a  point  of  counter  extension  to  the  pelvis,  which  is 
attached  by  a  belt  and  straps  to  the  foot  of  the  bed.  It  should 
be  remarked  that  the  extension  of  the  head  is  in  reality 
effected,  not  by  the  helmet,  but  by  a  stuffed  collar  of  iron 
suspended  from  its  lower  margin. 

M.  Guerin  finds  it  inexpedient  to  flex  simultaneously  the 
upper  and  lower  segments  of  the  bed;  and  when  there  are 
two  principal  curvatures  of  nearly  the  same  degree,  they 
are  treated  alternately  in  different  parts  of  the  day. 

When  there  is  a  single  principal  curve  for  which  the  mus- 
cles have  been  divided,  M.  Guerin  directs  attention  to  this, 


138  ORTHOPEDIC  SURGERY. 

to  the  exclusion  of  the  less  marked  curves  of  compensation. 
In  such  a  case,  the  body,  being  extended,  is  thrust  to  the 
side  of  its  concavity  by  the  aid  of  the  uprights  alone,  one 
of  which  is  applied  to  the  convex  point,  while  the  opposite 
antagonizes  the  pelvis.  The  two  portions  of  the  bed  are 
then  not  flexed. 

In  certain  scrofulous  and  other  deviations  unattended  by 
muscular  contraction,  simple  flexion  may  be  required,  with- 
out extension.  It  is  effected  by  a  bed  like  that  described, 
but  possessing  but  one  division,  with  its  axis  of  lateral 
flexion  at  a  point  equidistant  from  the  two  sides. 

The  apparatus  will  be  better  understood  by  referring  to 
Figures  31,  32,  33,  and  34. 


CONTRACTION   OF  THE   HAND   AND   FINGERS. 

The  section  of  tendons  in  the  hand  is  much  less  uniformly 
productive  of  good  results  than  in  many  other  regions,  and 
its  propriety  has  been  disputed.  The  indications  for  the 
operation  are  not  yet  clearly  pointed  out.  It  has  been  per- 
formed by  most  orthopedic  surgeons,  but  it  is  doubtful  if  it 
is  ever  efficacious,  while  it  is  certain  that  the  fingers  are 
sometimes  disabled  by  the  operation. 

CAUSES. 

The  distortion  is  sometimes  due  to  diseases  of  the  bone. 
That  form  which  is  owing  to  a  contraction  of  the  tendons, 
or  which  is  accompanied  by  this  symptom,  recognizes  a 
variety  of  exciting  causes.  It  is  occasionally,  but  rarely, 
congenital.  It  results  from  cutaneous  eruptions,  fractures, 
wounds,  or  abscesses.  It  also  follows  paralysis  of  antagoniz- 
ing muscles.     In  the  variety  thus  accompanied  by  active  or 


CONTRACTION  OF  THE   HAND   AND  FINGERS.  139 

"passive  muscular  retraction,  which  alone  offers  conditions 
for  tendinous  section,  the  tendons  are  resisting  and  in  high 
relief  beneath  the  skin. 

The  deformity  is  rarely  due  to  a  single  set  of  muscles,  and 
it  commonly  represents  a  combination  of  the  various  move- 
ments of  the  hand.  Flexion  of  the  hand  is  sometimes  ac- 
companied with  extension  of  the  fingers  or  with  a  lateral 
inclination,  and  with  flexion  of  the  phalanges.  The  muscles 
of  the  arm  not  unfrequently  participate  in  the  affection,  and 
the  forearm  is  more  or  less  flexed  or  pronated. 

It  has  been  demonstrated  by  Froriep,  of  Berlin,  that  the 
palmar  aponeurosis,  when  retracted,  may  aid  in  the  flexion 
of  the  phalanges  by  means  of  fibres  which  it  supplies  to  each 
side  of  the  fingers.  In  certain  cases  the  joints  are  partially 
anchylosed,  and  require  forcible  extension. 

The  section  of  the  flexor  tendons  of  the  fingers  is  fre- 
quently, if  not  in  all  cases,  followed  by  a  loss  of  power  in 
the  hand.  The  phalanges  can  no  longer  be  flexed.  It  has 
therefore  been  a  question  whether  their  division  should  ever 
be  attempted.  In  support  of  the  affirmative,  it  is  urged  that 
the  deformity  is  in  a  great  measure  relieved,  and  that  in 
unsuccessful  cases  the  hand  yet  retains  sufficient  power 
to  grasp  large  objects.  But  it  is  probable  that,  were  the 
chances  fairly  represented,  few  patients  would  consider  the 
shape  of  a  hand  an  inducement  to  hazard  the  loss  of  its  use ; 
and  the  histories  of  cases  like  that  of  M.  Doubouvitski  ^  will 

1  In  this  well  known  case,  many  tendons  of  the  forearm  and  hand  were 
divided  by  M.  Guerin,  among  them  the  deep  flexor  in  the  fingers  and  the 
snperficial  flexor  tendons  in  the  forearm.  The  patient,  who  before  was 
able  to  retain  an  object  in  the  contracted  fingers,  lost  all  power  of  flex- 
ing the  phalanges,  and  the  hand  became  in  consequence  comparatively 
useless. 

Similar  instances  are  not  wanting.  The  case  of  Jenny  Wilson,  reported 
by  M.  Guerin  to  the  Academie  des  Sciences  to  illustrate  the  innocuity 
of  the  division  of  thirteen  tendons,  was  examined  by  M.  Phillips,  a  year 


140  ORTHOPEDIC  SURGERY. 

deter  most  surgeons  from  attempting  the  division  of  the  ten- 
dons in  this  region. 

OPERATION. 

For  the  deviation  of  the  entire  hand,  which  is  rare,  it 
suffices  to  divide  the  palraaris  longus  and  brevis,  and  perhaps 
the  flexor  carpi  ulnaris  if  there  be  a  lateral  inclination  of  the 
hand.  These  tendons  are  subcutaneous,  and  easily  divided. 
The  motions  are  generally  restored  when  the  contraction  is 
not  due  to  paralytic  affection  of  the  antagonizing  muscles.  ^ 
More  commonly  the  flexors  of  the  fingers  are  also  retracted 
and  the  phalanges  drawn  toward  the  palm.  The  first  pha- 
lanx often  remains  straight,  while  the  last  two  are  flexed 
upon  it. 

After  dividing  the  flexors  in  the  forearm,  the  hand  may  be 
more  or  less  extended;  but  when,  as  it  often  happens,  the 
fingers  are  stiff  and  unyielding,  the  surgeon  is  required  to 
decide  upon  the  expediency  of  additional  sections  in  the 
palm  and  fingers.  In  such  a  case,  extension  may  be  some- 
times effected  by  force,  but  it  should  be  previously  ascer- 
tained that  the  resistance  is  not  due  to  the  retraction  of 
tendons  or  palmar  aponeurosis. 

As  was  before  stated,  the  division  of  the  tendons  of  the 
palm  and  fingers  is  rarely  successful.     The  section  of  the 

afterwards  at  the  Salpetriere.  He  sums  up  the  anatomical  details  as  fol- 
lows :  "  This  patient  remained  during  nine  months  in  the  service  of  M. 
Guerin  at  the  Hopital  des  Enf  ants.  She  bitterly  deplores,  as  well  as  her 
mother,  the  results  of  all  the  operations  she  has  undergone.  Before  these 
sections  she  could  make  a  movement  with  the  fingers  which  permitted  her 
to  hold  a  needle,  which  she  then  seized  with  the  mouth  to  be  again  taken 
by  the  fingers.  By  these  movements  she  could  sew  fast  enough  to  make 
shirts.  Now  this  sole  resource  no  longer  remains ;  she  is  condemned  to 
vegetate  in  a  ward  of  incurables  at  the  Hospice  de  la  Salpetriere.  The 
thirteen  sections  were  made  in  the  forearm,  in  the  two  legs,  and  two  feet." 
—  Annales  de  Chirm-gie,  Paris,  1841,  torn.  ii.  p.  130. 
^  Little,  in  Lancet,  December  16,  1843. 


CONTRACTION  OF  THE   HAND  AND  FINGERS.  141 

deep  flexors  at  the  level  of  the  second  phalanges  allows  the 
extension  of  the  fingers,  but  paralyzes  their  power  of  flexion. 
The  tendon  is  drawn  back  through  the  bifurcation  of  the 
superficial  flexor,  and  an  interval  is  thus  formed  between 
the  divided  surfaces,  which  are  hindered  from  uniting  by  the 
presence  of  the  synovial  fluid. 

In  the  present  state  of  knowledge  upon  this  subject,  it  may 
be  affirmed  that  the  superficial  flexors  of  the  fingers  should 
never  be  divided  at  the  base  of  the  first  phalanx,  but  rather 
in  the  forearm.  The  proximity  of  the  median  nerve  at  the 
wrist  compels  us  to  divide  the  deep-seated  flexors  in  the 
palm,  if  at  all ;  but  the  reunion  of  their  tendons  is  uncer- 
tain. The  operation  is  indicated  only  when  a  single  finger 
is  permanently  flexed,  and  interferes  with  the  movements  of 
the  others. 

The  flexors  of  the  toes  are  sometimes  retracted,  and  may 
be  divided  in  the  sole,  the  re-establishment  of  motion  being 
here  of  comparatively  little  importance. 

Little  benefit  is  obtained  in  most  cases  from  a  simple 
division  of  the  cicatrices  consequent  upon  burns,  especially 
upon  the  palmar  surface. 

MECHANICAL   TREATMENT. 

Immediately  after  the  section  the  patient  is  apt  to  experi- 
ence severe  and  deep-seated  dragging  pain  in  the  arms,  due 
to  the  forcible  contraction  of  the  muscles.  The  pain  is  alle- 
viated by  frictions  and  steaming. 

The  hand,  being  well  protected,  is  confined  in  contact  with 
a  straight  splint,  extending  from  the  elbow  to  the  extremities 
of  the  fingers.  The  splint  may  be  provided  at  the  wrist 
with  a  hinge  regulated  by  a  screw  or  other  mechanism,  so 
contrived  as  to  fix  it  at  any  required  angle.  The  whole  may 
be  supported  in  a  sling. 


142  ORTHOPEDIC  SURGERY. 


CONGENITAL   DISLOCATIONS. 

Numerous  well  described  cases  of  the  different  varieties  of 
congenital  luxation  are  to  be  found  in  the  papers  of  various 
writers,  especially  since  the  subject  has  received  general 
attention.  Although  interesting,  in  an  anatomical  and 
pathological  point  of  view,  they  are  generally  to  be  referred 
to  the  principles  laid  down  by  Guerin  in  his  memoir  upon 
this  subject,  which  is  the  groundwork  of  this  section. 

CAUSES. 

Certain  forms  of  congenital  dislocation  are  due  to  the 
paralysis  of  muscles. 

Luxation  resulting  from  disease  of  the  bone  is  unaccom- 
panied with  active  muscular  retraction,  and  is  easily  distin- 
guished. 

The  affection  is  due  in  a  large  majority  of  cases  to  muscu- 
lar retraction,  and  resembles  in  this  respect  club-foot  and 
wry -neck.  It  accompanies  these  distortions,  and  like  them 
is  found  in  acephalous  foetuses  and  in  other  abnormal  con- 
formations of  the  nervous  system. 

LOCALITY   AND   PROGRESS. 

Any  joint  in  the  body  is  liable  to  congenital  dislocation 
from  muscular  retraction. 

The  luxation  may  be  partial  or  complete.  At  an  early 
period  of  foetal  life  the  articulating  cavities  are  imperfectly 
formed,  and  the  articular  extremities  easily  extend  the 
yielding  ligaments,  and  escape  from  their  normal  positions. 
At  a  later  period,  when  the  sockets  are  more  completely 
developed,  the  dislocation  is  commonly  partial. 

The  progress  of  the  luxation  is  due  to  the  arrest  of  the 


CONGENITAL  DISLOCATIONS.  143 

development  of  certain  muscles;  to  the  physiological  con- 
traction of  others ;  and  to  the  superincumbent  weight  of  the 
body.  These  forces  eventually  make  a  dislocation  complete 
which  was  at  birth  only  partial.  In  such  cases,  an  indeter- 
minate length  of  time  is  required  to  complete  the  luxations. 
The  femur  rarely  escapes  from  the  acetabulum  in  less  than 
three  or  four  years  after  birth ;  and  surgeons  have  been  thus 
led  to  suppose  the  affection  non-congenital. 

An  essential  step  towards  the  reduction  of  the  dislocation 
is  the  division  of  the  retracted  muscles,  whether  actively 
or  passively  affected. 

CONDITION    OF   THE   MUSCLES    AND    SOFT   PARTS. 

The  muscles  originally  concerned  in  inducing  the  luxation 
are  actively  retracted.  Others,  passively  retracted,  merely 
accommodate  themselves  to  the  approximated  points  of  inser- 
tion.    Their  direction  is  often  changed. 

Their  texture  is  either  fibrous  when  tense,  fatty  when 
exempt  from  traction,  or  hypertrophied  when  tasked  with 
the  duties  of  muscles  no  longer  efficient. 

Muscles  primarily  retracted  require  division.  Those 
passively  shortened  may  be,  in  certain  cases,  mechanically 
extended,  but  sometimes  require  division.  The  fatty  tissue 
opposes  no  obstacle  to  the  normal  position  of  the  part. 

The  arteries  become  flexuous,  and  retain  their  length,  but 
decrease  considerably  in  volume. 

The  veins  increase  in  number  and  in  size. 

The  nerves  are  shortened,  probably  through  the  agency  of 
their  fibrous  sheath ;  and  their  mechanical  extension  during 
treatment  is  attended  with  pain. 

The  cellular  tissue  increases  in  quantity,  fills  up  depres- 
sions, and  takes  the  place  of  the  atrophied  muscular  fibre. 

Tlie  skin  adapts  itself  to  the  conformation  of  the  subjacent 
parts,  being  often  cushioned  in  depressions  by  adipose  matter. 


144  ORTHOPEDIC  SURGERY. 

The  ligaments  and  capsules,  like  the  muscles,  are  changed 
in  form,  dimensions,  and  texture.  They  may  be  actively 
retracted  as  well  in  congenital  dislocation  as  in  other  de- 
formity. In  extreme  adduction  of  the  foot,  the  internal 
lateral  ligament  of  the  tibio-tarsal  articulation  and  the 
astragalo-scaphoidean  ligament  are  sometimes  reduced  to  a 
third  or  a  quarter  of  their  normal  length.  In  the  same  way 
the  external  lateral  ligament  of  the  knee  offers  an  obstacle 
to  the  correction  of  internal  deviation  of  this  joint.  The 
ligaments  are  also  subject  to  passive  retraction,  merely  ac- 
commodating themselves  to  their  approximated  points  of 
insertion. 

When  extended,  they  become  thinner  and  longer.  Like 
the  muscles,  they  are  subject  to  fatty  transformation  when  in 
a  state  of  continuous  repose,  though  to  a  less  degree.  Under 
circumstances  which  produce  fibrous  transformation  of  the 
muscles,  the  ligaments  tend  to  become  ossified,  a  condition 
which  is  also  the  occasional  effect  of  rest  alone. 

The  articular  capsule  of  the  femur,  when  extended  gradu- 
ally, acquires  the  form  of  a  double  cone  united  at  its  apices. 

In  fine,  the  ligaments  and  capsules,  when  retracted,  offer 
invincible  obstacles  to  reduction  by  unaided  mechanical 
force ;  and  when  elongated,  they  constitute  a  serious  impedi- 
ment to  any  efforts  in  maintaining  reduction. 

The  cavity  of  the  capsular  ligament  of  the  head  of  the 
femur,  has  been  found  to  be  obliterated  in  old  subjects,  a  fact 
upon  which  has  been  founded  an  argument  against  attempts 
at  reduction.  This  condition  does  not  prevail  in  young  sub- 
jects, and  is  rarely  a  serious  obstacle  to  reduction  until  the 
patient  attains  the  age  of  twelve  or  fourteen  years.  The 
continuity  has  been  found  to  exist  even  in  subjects  of 
twenty,  twenty-five,   or  thirty  years  of  age. 

Alterations  of  the  Articular  Extremities.  —  The  head  of  the 
femur,  for  example,  is  diminished   in  size,  while  its  neck 


CONGENITAL  DISLOCATIONS.  145 

becomes  shorter  and  more  horizontal.  It  may  be  flattened 
or  grooved  by  pressure  against  the  edge  of  the  socket  or 
other  neighboring  parts. 

When  no  longer  lubricated  by  the  synovial  fluid,  its  sur- 
face loses  its  polish,  and  becomes  rough,  while  the  cartilage 
gives  place  to  bone. 

Articular  Cavities.  —  The  cotyloid  cavity  is  especially  the 
seat  of  alteration.  It  tends  to  become  both  superficial  and 
triangular,  in  a  fashion  corresponding  to  the  triple  forma- 
tion of  the  OS  innominatum. 

The  articular  cavities  are  obliterated  in  proportion  to 
their  original  depth  and  the  date  of  the  lesion.  This  is 
effected :  —  1.  By  a  rising  up  of  the  bottom  of  the  socket, 
which  seems  to  result  from  the  absence  of  pressure.  2.  From 
the  production  of  a  cellular  fatty  tissue,  apparently  due  to 
hypertrophy  and  degeneration  of  the  normal  tissues  of  the 
base  of  the  cavity. 

When  the  luxation  is  partial,  the  cavity  yields  before  the 
continued  pressure  of  the  head  of  the  bone  in  the  direction 
of  the  force  which  it  exerts. 

These  conditions  may  be  thus  summed  up,  with  reference 
to  the  reducibility  of  the  luxation. 

When  the  head  of  the  bone  has  escaped  from  its  socket, 
and  no  new  socket  has  been  formed,  both  the  articular  ex- 
tremity and  cavity  proportionately  diminish  in  size.  This 
circumstance,  while  it  facilitates  reduction,  impedes  subse- 
quent movement.  The  reduction,  however,  tends  to  induce 
the  parts  to  resume  their  normal  size.  If  the  head  of  the 
bone  has  formed  a  new  socket,  it  retains  nearly  its  original 
dimensions,  a  condition  which  hinders  it  from  entering  the 
atrophied  socket  and  prevents  reduction. 

The  grooves  and  other  irregularities  in  the  conformation 
of  the  articulating  extremity  interfere  both  with  reduction 

and  subsequent  movement. 

10 


146  ORTHOPEDIC  SURGERY. 

After  reduction,  the  articular  deformities  and  the  relaxa- 
tion of  the  capsules  facilitate  the  recurrence  of  luxation. 

The  change  both  of  bones  and  soft  parts  is  gradual  and 
slow,  so  that,  although  these  luxations  are  not  at  first  irre- 
ducible, they  become  so  after  a  time.  Guerin  has  reduced 
congenital  dislocation  of  the  femur  of  ten  years'  standing, 
and  M.  Guillard  has  reported  a  similar  case  of  permanent 
reduction  of  a  scapulo-humeral  luxation  in  a  girl  sixteen 
years  of  age. 

Congenital  dislocation  is  not  due  to  a  simple  arrest  of 
development  of  the  bony  structure.  If  the  bones  be  ex- 
amined at  an  early  period  after  luxation,  they  are  found 
unchanged. 

ALTERATIONS   OF  PARTS  IN  THE  NEIGHBORHOOD   OF  LUXATIONS. 

New  articular  cavities  are  sometimes  formed,  and  some- 
times not.  They  are  rarely  developed  before  the  age  of 
twelve  or  fourteen,  but  the  period  of  their  formation  varies. 
In  an  old  woman  of  seventy-three,  with  double  congenital 
luxation  of  the  hip,  one  new  cavity  was  formed,  while  the 
other  side  presented  merely  a  slight  depression. 

With  regard  to  the  conditions  which  aid  in  establishing 
the  new  socket,  M.  Guerin  declares  it  to  be  a  law  that  such 
cavities  are  formed  only  when  the  capsular  ligament  is 
ruptured  and  the  head  of  the  bone  is  placed  in  contact  with 
the  bone  upon  which  it  lies. 

When  the  new  joint  is  formed,  the  ruptured  capsule  con- 
tracts firm  adhesions,  which  preclude  all  chance  of  displacing 
the  bones,  except  by  unjustifiable  violence. 

When  there  is  no  new  joint,  the  head  of  the  bone  is  finally 
bound  down  by  fibrous  cords,  which  require  subcutaneous 
division. 

Alterations  of  the  Skeleton.  — These  are  especially  observed 
near  the  hip.     Contrary  to  the  opinion  of  Dupuytren,  the 


CONGENITAL  DISLOCATIONS.  147 

pelvis  often  suffers  in  these  cases,  as  has  been  shown  by  M. 
Sedillot. 

When  one  femur  is  luxated  upward  and  outward,  the  pel- 
vis of  that  side  is  carried  upward,  backward,  and  outward. 
The  whole  pelvis  is  flattened  obliquely,  the  pubes  being  car- 
ried beyond  the  median  line  towards  the  healthy  side. 

The  OS  innominatum  of  the  affected  side  becomes  more 
perpendicular,  and  that  side  of  the  pelvis  is  elevated. 

INDICATIONS   FOR   REDUCTION. 

From  examinations  of  the  pathological  conformation  of 
the  parts  in  different  stages  of  lesion,  it  results  that  con- 
o-enital  luxations  are  reducible  in  certain  conditions;  that 
they  are  less  so  in  proportion  to  the  degree  and  long  standing 
of  the  deformity ;  that  they  are  wholly  irreducible  when  very 
old,  and  principally  when  accompanied  with  new  articular 
cavities ;  and,  finally,  that  the  permanence  of  the  reduction 
is  in  proportion  to  its  facility. 

MEANS   OF   PREPARING    FOR,   EFFECTING,   AND    CONSOLIDATING 
REDUCTION   IN   ALL   ARTICULATIONS. 

Preparatory  and  continued  extension,  which  counteracts 
the  displacement  due  to  superincumbent  weight,  and  brings 
into  view  the  retracted  muscles. 

The  subcutaneous  section  of  muscles  which  refuse  to  yield 
to  extension. 

Continued  extension  of  the  ligaments,  and  their  subcuta- 
neous section  if  required. 

The  reduction  of  the  luxation. 

The  consecutive  treatment,  of  which  the  indications 
are:  — 

Apparatus  of  extension  to  elongate  the  muscles  and  liga- 
ments not  divided,  and  to  extend  those  which  have  been 
divided. 


148  ORTHOPEDIC  SURGERY. 

Force  so  applied  as  to  maintain  the  articular  surfaces  in 
contact,  and  to  exercise  continued  pressure  upon  the  part 
destined  to  form  a  new  socket. 

Gradual  motion  in  imitation  of  the  normal  movement  of 
the  part,  to  wear  away  as  it  were  a  depression  for  the  articu- 
lations, and  to  establish  its  functions. 

An  indication  derived  from  the  fact  that  the  capsule  must 
be  ruptured,  and  the  bones  placed  in  contact  before  a  new 
articulation  can  be  established. 

M.  Guerin  therefore  practices  subcutaneous  perforation 
of  the  capsule,  and  scarification  of  the  ligaments,  to  pro- 
mote an  inflammatory  action,  which  may  induce  their  firm 
adhesion. 

In  this  way  M.  Guerin  reduced  a  congenital  dislocation 
of  the  sternal  extremity  of  the  clavicle  in  a  girl  thirteen 
years  of  age,  which  had  been  many  times  attempted  without 
success.  He  scarified  the  capsular  ligament,  and  repeated 
the  operation  at  the  end  of  ten  days.  The  extremity  of 
the  bone  was  confined  in  its  place,  and  in  a  month  the 
ligaments  were  firmly  retracted,  and  the  arm  was  capable 
of  executing  its  normal  movements  without  a  renewal  of 
the  luxation. 


RECENT  AND   CHRONIC   DISLOCATIONS. 

The  tendons  not  unfrequently  form  a  serious  impediment 
to  the  reduction  of  accidental  dislocations  of  long  standing, 
especially  of  the  humerus  and  olecranon.  They  have  been 
not  unfrequently  divided  in  these  cases  by  the  subcutaneous 
operation,  and  the  limb  has  been  thus  replaced  with  compar- 
ative ease. 

The  pectoralis  major,  latissimus  dorsi,  and  teres  major 


SECTION  OF   MUSCLES  IN  LOCKED  JAW.  149 

and  minor  muscles,  have  been  thus  divided  for  the  purpose 
of  reducing  a  dislocation  of  the  shoulder  of  long  standing. 

I  have  seen  M.  Berard  divide  the  tendo  Achillis  for  the 
purpose  of  facilitating  the  reduction  of  a  recently  dislocated 
foot,  which  was  thus  easily  replaced,  and  the  patient  subse- 
quently recovered  its  use.  Several  similar  cases  are  reported 
in  the  journals  by  this  surgeon,  and  by  other  writers. 

In  the  reduction  of  a  dislocation  of  the  foot,  of  long  stand- 
ing, accompanied  with  the  formation  of  an  artificial  tibio- 
tarsal  joint,  M.  Bonnet  divided  the  tibialis  posticus,  the 
extensors  of  the  toe  and  of  the  great  toe,  and  finally  all  the 
fibrous  tissue  of  new  formation. 


SECTION  OF  MUSCLES   IN   LOCKED   JAW. 

Certain  rare  forms  of  this  affection  are  due  to  bony  anchy- 
losis, for  which  M.  Berard  has  proposed  a  section  near  the 
condyles  analogous  to  that  practised  in  Barton's  operation 
for  anchylosed  hip. 

The  more  common  form  results  from  muscular  contrac- 
tion. For  such  cases  M.  Bonnet  ^  proposes  the  section  of 
the  masseter  and  temporal  muscles,  as  an  aid  to  ordinary 
mechanical  means  for  separating  the  teeth.  The  masseter 
is  best  divided,  according  to  Bonnet,  in  its  superior  fifth. 
Below  this  point  it  adheres  to  the  lower  jaw  and  is  covered 
behind  by  the  parotid  gland.  The  tenotome  is  entered  at 
the  anterior  border  of  the  muscle  just  below  the  zygomatic 

1  M.  Bonnet  effected  the  division  of  the  masseter  muscle  on  October 
16,  1841.  It  had  been  performed  by  Dr.  Schmidt  of  New  York  on  the 
8th  of  the  same  month.  See  Boston  Medical  and  Surgical  Journal, 
July,  1842. 


150  ORTHOPEDIC   SURGERY. 

arch,  and  carried  behind  it  as  far  as  the  coronoid  process 
of  the  lower  jaw.  The  muscle  is  then  divided  from  within 
outward. 

The  temporal  muscle  may  be  divided  above  or  below  the 
arch.  It  is  best  divided  below,  unless,  as  in  old  patients, 
the  coronoid  process  is  so  long  as  to  impede  the  progress  of 
the  knife.  The  muscle  may  be  always  divided  above  the 
arch,  but  its  substance  is  less  tendinous,  and  the  hemorrhage 
from  the  deep-seated  temporal  artery  is  considerable. 

In  the  section  beneath  the  zygomatic  arch,  the  tenotome  is 
entered  at  nearly  the  same  point  as  for  the  section  of  the 
masseter,  and  directed  towards  the  tuberosity  of  the  superior 
maxillary.  The  blade  is  then  passed  backwards,  between 
the  external  pterygoid  and  the  temporal  muscles,  until  it 
reaches  the  articulation,  when  the  muscle  is  divided  from 
within  outwards.  The  coronoid  process  is  occasionally  an 
insurmountable  obstacle  to  the  section  in  this  region. 

Above  the  malar  bone  the  blade  is  entered  just  in  front  of 
the  temporal  artery  and  carried  to  the  bone,  in  contact  with 
which  it  remains  until  it  reaches  the  posterior  part  of  the 
malar  bone.  The  edge  is  then  turned  outward,  and  the 
muscle  divided.  Both  the  muscles  may  be  simultaneously 
divided. 

In  one  case  in  which  M.  Bonnet  applied  these  methods,  a 
slight  amelioration  was  obtained.  The  patient  was  old,  and 
the  affection  of  long  standing. 

The  operation  of  Dr.  Schmidt  was  followed  by  immediate 
relief  in  a  case  of  locked  jaw  of  twelve  years'  standing. 


ORBICULAR  MUSCLES.  151 


SUBCUTANEOUS   SECTION  OF   THE   ORBICULAR 
MUSCLES. 

These  muscles  have  been  subcutaneously  divided,  with 
good  results,  for  various  affections;  that  of  the  mouth  for 
deviation  of  one  of  the  angles,  which  after  operation  as- 
sumed its  normal  position;^  that  of  the  eye,  by  Cunier,  for 
ectropion;  the  sphincter  of  the  anus,  by  Blandin,  Bracliet, 
and  others,  in  cases  of  fissure  of  the  anus. 

M.  Phillips  affirms  that  the  orbicular  muscles  are  not 
formed  of  circular,  but  of  straight  fibres,  obliquely  disposed, 
and  attached  by  one  extremity  to  a  median  line,  and  by  the 
other  to  an  aponeurotic  circle  which  surrounds  them. 

This  he  infers  from  the  irregular  form  of  the  mouth  in  the 
spasmodic  action  of  its  orbicular  muscle,  and  from  the  fact 
that,  in  drawing  upon  the  fibres  in  any  direction,  the  orifice 
is  distorted,  and  a  chord  instead  of  an  arc  is  produced  by  the 
traction. 

The  relief  obtained  by  the  division  of  the  orbicular  muscle 
of  the  eye,  in  the  case  of  ectropion  operated  on  by  M.  Cunier, 
and  above  referred  to,  seems  to  confirm  this  theory. 

1  Phillips,  Tenotomie  Souscutanee,  p.  204. 


152  ORTHOPEDIC  SURGERY. 


APPENDIX. 

In  the  treatment  of  deformity,  it  is  common  at  the  outset  to 
take  a  cast  in  plaster  of  the  distorted  region,  which  may  be  after- 
wards compared  with  a  cast  taken  at  a  subsequent  time.  The 
result  of  orthopedic  treatment  is  in  this  way  readily  appreciated. 

In  casting  entire  limbs  some  little  dexterity  is  requisite.  The 
tendency  of  the  dried  or  anhydrous  sulphate  of  lime  to  set,  or 
form  a  solid  hydrate  when  mixed  with  water,  is  well  known,  and 
most  people  are  familiar  with  the  general  features  of  the  process 
of  casting  in  plaster.  But  there  are  some  details  connected  with 
manipulation  in  casting  large  masses,  and  in  taking  moulds  from 
the  living  subject,  which  deserve  to  be  mentioned.  I  have  there- 
fore written  out  the  following  description  of  the  process,  most 
of  which  I  obtained  from  the  mouleur  attached  to  M.  Guerin's 
establishment. 

ISTo  tools  are  a  substitute  for  the  hand,  which  is  in  contact  with 
the  plaster  during  the  whole  process.  The  only  utensils  required 
are  a  stiff  spatula  of  wood,  or  better  of  iron,  a  bowl,  and  a  chisel 
and  mallet. 

The  necessary  quantity  of  plaster  must  be  mixed  at  once.  It 
is  evidently  better  to  exceed  than  to  fall  short  of  the  required 
amount. 

The  most  convenient  vessel  is  a  basin  or  common  earthen  pan 
with  flaring  sides.  Into  this  water  at  the  temperature  of  about 
one  hundred  degrees  is  first  poured.^  The  calcined  plaster  is 
then  taken  in  large  handfuls,  supported  by  the  open  palm  and 
fingers  which  are  slightly  separated,  and  gradually  sprinkled 
into  the  water  by  a  sort  of  undulating  movement  of  the  fingers. 
In  this  manner  the  water  attacks  each  particle  as  it  falls,  and 
hinders  the  formation  of  lumps,  which  it  is  afterwards  difiicult 
to  break  up.  The  powder  is  thus  continuously  added  until  it  is 
so  heaped  up  that  it  begins  to  appear  above  the  surface.  Half 
a  minute  is  allowed  to  elapse  to  enable  the  water  to  penetrate 
it  thoroughly,  after  which  the  mass  is  stirred  with  the  spatula 

1  Cold  water  subjects  the  patient  to  unnecessary  exposure. 


APPENDIX.  153 

until  it  assumes,  at  the  end  of  a  minute,  a  uniform  consistence  of 
the  density  of  thick  syrup.     It  is  then  ready  for  use. 

The  plaster  is  placed  in  contact  with  the  object,  of  which  a 
cast  is  desired,  and  when  hard  is  removed.  It  then  constitutes 
a  mould  into  which  a  fresh  quantity  of  plaster  is  subsequently 
poured.  The  last  should  present  when  withdrawn,  a  fac-simile 
of  the  original. 

It  is  evident  that  solid  objects  require  a  mould  of  several 
pieces,  which  multiply  in  proportion  to  the  complicated  form 
and  unyielding  material  of  the  model.  Flesh  and  other  soft 
tissues  yield  to  the  projecting  angles  of  the  mould,  and  the 
number  of  its  pieces  is  thus  considerably  diminished.  It  is  rare 
that  a  human  limb  or  trunk  requires  a  mould  of  more  than  two 
pieces. 

The  divisions  are  made  by  means  of  a  strong  thread,  which  is 
applied  to  the  limb  before  the  plaster  is  laid  on,  and,  being  with- 
drawn by  its  loose  ends  when  the  plaster  is  half  hardened,  it  cuts 
its  way  out  and  bisects  the  mould.  The  position  of  the  string  as 
a  general  rule  is  as  follows. 

On  the  leg,  from  the  superior  insertion  of  the  rectus  muscle, 
over  the  patella,  along  the  tibia  to  the  outer  side  of  the  great  toe, 
and  by  the  centre  of  the  sole,  heel,  and  ham,  to  the  tuberosity  of 
the  ischium.  A  better  division  is  from  the  great  trochanter  to 
the  head  of  the  fibula;  thence  to  the  centre  of  the  external  mal- 
leolus, and  along  the  external  edge  of  the  foot  to  the  edge  of  the 
little  toe  and  the  end  of  the  great  toe ;  then  back  to  the  internal 
malleolus,  the  internal  condyle  of  the  femur,  and  the  superior 
insertion  of  the  adductor  muscles. 

The  arm  is  divided  by  a  line  from  the  insertion  of  the  pectoral 
muscle  to  the  styloid  process  of  the  pronated  radius,  and  by 
the  radial  edge  of  the  hand  and  the  tips  of  the  fingers  to  the 
styloid  and  coronoid  process  of  the  ulna  and  the  region  of  the 
deltoid.  If  the  fingers  be  separated,  the  string  is  to  be  carefully 
carried  to  the  base  of  each,  upon  the  edge  which  separates  the 
palmar  and  dorsal  surfaces. 

Upon  the  trunk,  the  line  passes  over  the  back  of  the  neck  a 
little  before  one  shoulder  to  the  great  trochanter  on  one  side,  and 
behind  the  other  shoulder  to  a  point  just  behind  the  trochanter 
of  the  opposite  side. 


154  ORTHOPEDIC  SURGERY. 

The  action  of  respiration  commonly  breaks  the  mould  upon 
the  anterior  surface  of  the  trunk,  and  the  pieces  are  to  be  sub- 
sequently put  together. 

The  mould  of  the  head  requires  but  two  pieces,  separated  be- 
fore and  behind  on  the  median  line,  or,  which  is  better,  by  a  line 
over  the  vertex,  passing  before  one  ear  and  behind  the  other. 
Such  an  oblique  division  obviates  the  difficulty  presented  by  cor- 
responding prominences  on  opposite  sides  of  the  original.  They 
are  thus  distributed  between  the  two  halves  of  the  mould.  The 
hair  is  covered  by  an  oiled  napkin  and  the  ears  are  plugged  with 
cotton. 

The  head  is  commonly  included  in  a  cast  of  the  neck ;  a  per- 
pendicular position  is  necessary.  The  soft  plaster  then  flows  off 
from  the  sides  of  the  nose  without  obstructing  respiration.  In 
the  horizontal  position,  quills  or  paper  tubes  are  placed  in  the 
nostrils. 

A  perpendicular  position  is  required  to  disj^lay  the  action  of 
the  muscles  of  the  neck  or  trunk,  while  the  limbs  may  be  cast 
horizontally.  When  permanently  flexed,  the  plaster  is  kept  in 
contact  with  their  inferior  surface  by  a  sort  of  bed  formed  by 
a  sheet  of  stiff  paper  supported  by  straw. 

As  a  slight  motion  breaks  the  plaster  before  it  is  hardened, 
young  children  require  to  be  confined  during  the  process. 

If  a  leg,  for  example,  is  to  be  cast,  the  plaster  is  prepared  as 
before  indicated ;  some  of  the  thinner  plaster  is  then  applied  with 
the  hand  to  the  external  and  internal  surfaces  of  the  limb,  and 
by  means  of  this  the  string  is  made  to  adhere,  care  being  taken 
to  bring  it  in  contact  with  the  skin  at  every  point.  The  limb  is 
then  gradually  covered,  and  the  plaster  as  it  thickens  is  applied 
with  the  hand  till  it  attains  a  depth  of  from  one  to  three  inches. 
The  string  is  withdrawn  while  the  plaster  is  yet  soft,  and  the 
mould  thus  divided  is  allowed  to  harden.  The  mass  grows  warm, 
and  it  is  just  before  its  maximum  heat,  when  a  fragment  pressed 
between  the  thumb  and  finger  breaks  as  if  dry  and  brittle,  that  it 
is  to  be  taken  off.  If  the  plaster  by  accident  becomes  too  hard, 
so  that  the  string  breaks,  the  mould  is  to  be  broken  with  a  chisel 
and  mallet,  and  the  fragments  are  subsequently  united  by  a  layer 
of  plaster  applied  to  the  outside. 

In  casting  the  back,  the  model  is  seated  upon  a  table,  and,  the 


APPENDIX.  155 

hairs  of  the  neck  being  matted  together  with  soft  soap,  the  plaster 
is  applied  with  the  hand  to  the  upper  part  of  the  neck  and  shoul- 
ders, and  allowed  to  stream  down  the  back.  As  it  attains  consist- 
ence it  adheres  to  the  skin  and  may  be  built  up. 

The  interior  surface  of  the  mould  thus  formed  is  immediately 
painted  over  with  a  mixture  of  soft  soap  and  water,  and  when 
saturated  the  superfluous  soap  is  removed  and  a  thin  coat  of  oil 
applied.  If  composed  of  pieces,  these  are  united  and  the  mould 
is  then  ready  for  the  cast.  Plaster  is  prepared  as  before,  poured 
into  the  interior  withovit  delay,  and  allowed  to  set. 

At  the  expiration  of  fifteen  minutes  the  mould  must  be  broken 
ofE  in  small  fragments  with  a  chisel  and  mallet,  and  is  hence  said 
to  be  lost  (stampa  persa).  During  this  operation  the  cast  is  held 
in  the  lap,  and  the  blows  should  be  given  in  the  direction  of  the 
axis  which  presents  the  greatest  inertia.  The  mould  is  thus 
readily  detached;  its  entire  superior  surface  being  removed  be- 
fore the  base  is  attacked. 

If  the  cast  be  not  immediately  made,  the  mould  becomes  dry, 
and  must  be  soaked  in  water  before  the  application  of  the  soap. 
If  the  operation  be  delayed  for  several  days,  the  plaster  of  the 
mould  becomes  so  hard  as  to  be  with  difficulty  broken.  If  the 
cast  be  allowed  to  remain  a  few  hours  in  the  mould,  the  oil  is 
absorbed  and  the  surfaces  are  with  difficulty  separated. 

If  a  duplicate  cast  be  desired,  a  permanent  mould  {stampa  huona) 
is  made  upon  this  first  cast,  which  then  serves  as  the  model.  The 
model  is  well  oiled  and  plaster  is  applied  in  small  masses,  each 
capable  of  being  detached  from  its  various  curves  and  angles. 
The  first  piece  is  detached  and  its  edges  squared  with  a  sharp 
knife,  after  which  it  is  oiled  and  replaced  to  aid  in  the  formation 
of  the  next.  These  fragments  are  numerous  when  the  model 
is  complicated.  Drapery,  and  statuettes  such  as  are  common  in 
the  shops,  sometimes  require  several  hundred,  which  are  kept 
in  place  by  an  outer  covering  or  garment  (camisia)  of  plaster  in 
large  fragments.  When  dry,  the  mould  is  heated  and  saturated 
with  boiled  linseed  oil  at  a  high  temperature.  This  gives  te- 
nacity to  the  plaster,  and  secures  when  cold  a  polished  surface, 
which  needs  only  to  be  oiled  when  a  cast  is  required.  The 
pieces  are  detached  in  the  inverse  order  of  their  formation,  and 
such  a  mould  yields  an  indefinite  number  of  casts. 


156  ORTHOPEDIC  SURGERY. 


DESCRIPTION  OP  PLATES. 


STRABISMUS.— Plate  I. 

Fig.    1.  Speculum  for  upper  or  lower  Lid. 

"       2.  Hook  for  Conjunctiva. 

"       3.  Double  Hook  for  Sclerotic. 

"      4.  "  Crochet  Bistouri  "  of  Baudens,  with  Porte  Sponge. 

"      5.  Blunt  Hook  of  Dielfenbach. 

"      6.  Tenotome  of  Guerin.     (See  p.  21.) 

"      7.  Side  view  of  Tenotome  of  Guerin. 

"     13.  Snowden's  Blephareirgon,  modified. 


TENOTOMY.— Plate  I. 

Common  pointed  Tenotome. 

Common  blunt  Tenotome. 

Myotome  for  Dorsal  Muscles. 

Front  view  of  the  same. 

Guerin's  Tenotome  for  Sterno-cleido-mastoid  Muscle. 

Self-acting  Speculum  for  Lids. 


CLUB-FOOT.     EQUINUS.  — Plate  IL 

Fig.  14.     Foot-board  of  Stromeyer.     (See  p.  82.) 
"     15.     Scarpa's  Boot,  and  Sole  of  the  same.     (See  p.  82.) 

"     17.  I  Graduated  Movement. 


F 

ig- 

8. 

9. 
10. 
11. 
12. 
13. 

18. 


DESCRIPTION  OF  PLATES.  157 


CLUB-FOOT.    VARUS.— Plate  ni. 

Fig.  19.     Contrivance  for  reducing  Varus  to  Equinus.     (See  p.  83.) 
"     20.    Dieffenbach's  Contrivance  for  the  same.     (See  p.  83.) 
"     21.    Little's  Apparatus  for  treatment  of  Varus,    a,  pivot  for  the 
metal  leg  piece,  of  which  the    movements  of  flexion  and 
extension  are  limited  by  the  shoulders,  c  and  b,  of  the  hori- 
zontal screw  traversing  the  collar  c.    d,  fixed  metal  attach- 
ment for  toe  strap,     e,  strap  to  bring  down  the  heel. 
"    22.  )  Duval's  apparatus  for  Varus,    a,  leg  piece  governed  by  a  grad- 
"    23.  )        uated  universal  joint  at  c.     (See  Fig.  17.) 
«    22.     Oblique  view  of  the  same,  to  show  b,  a  cushioned  metal  plate 
of  which  the  posterior  edge  is  advanced  against  the  heel 
by  screws,  a,  working  in  the  plate  c.    d,  key  for  perpetual 
screws. 


TORTICOLLIS.— Plate  IV. 

Fig.  24.  Minerva  of  Delacroix  modified  by  Bouvier.  (See  p.  95.) 
a,  metal  band  for  pelvis,  b,  metal  upright,  c,  shoulder 
straps,  d,  head  band,  e,  vertical  head  band.  /,  chin  strap. 
g,  metal  upright  at  back  of  neck.  I,  pin  to  regulate  its 
length,  i,  graduated  flexion,  governed  by  g.  k,  graduated 
rotation.  (See  Fig.  16.)  m,  joint  permitting  extension  but 
not  flexion,     n,  graduated  lateral  movement. 

"  25.  Phillips's  Cravat.  (See  p.  96.)  a,  collar,  fe,  metal  upright 
(see  Fig.  27)  capable  of  being  raised  or  depressed,  c,  back 
piece,  confined  by  waist  strap  and  shoulder  straps. 

"     27.     Back  view  of  Fig.  25. 

"  26.  Bonnet's  Apparatus,  a,  cap  for  knee,  b,  carriage  for  foot, 
drawn  upon  wheels,  b,  towards  d,  by  weight  or  otherwise. 


FALSE  ANCHYLOSIS  OF  KNEE  JOINT.  — Plate  V. 


°'  "  ■  [■  Duval's  Apparatus. 


.30.) 

29.  Little's  Apparatus.  (See  p.  104.)  a,  extension.  /,  counter 
extension,  e,  cap  for  depressing  knee,  h,  stiff  pad  for  sup- 
porting head  of  tibia  by  means  of  c,  straps,  d,  screw  for 
applying  lateral  force  to  head  of  tibia. 


158  ORTHOPEDIC  SURGERY. 


LATERAL  CURVATURE   OF  THE  SPINE.  — Plate  VL 

Fig.  31.  Guerin's  bed  for  sigmoid  extension.  (See  pp.  136-138.)  a,  up- 
per table,  b,  lower  table.  (See  Fig.  31.)  c,  middle  table. 
(See  Fig.  32.)  d,  spring  to  impart  elasticity  to  e,  the  point 
of  counter  extension,  supporting  the  helmet.  (See  Fig.  31.) 
/,  slide  for  the  support  of  d.  g,  g,  to  support  the  middle 
table  of  the  bed.      h,  h,  lateral  centres  of  flexion. 

"  34.  Part  of  the  same  furnished  with  its  cushions,  d,  d,  lateral  up- 
rights attached  to  the  upper  and  middle  tables,  and  capable 
of  being  advanced  upon  the  convexity  of  the  spiral  curves. 

"     32.     Bed  for  parallel  extension  and  simple  flexion. 

"     33.     Helmet  with  its  collar  and  apparatus  for  lateral  flexion. 


Tcimotoiiity. 


]E<[|mi"inLTifl.3 . 


PLATE   II. 


Iisr  U 


PLATE   IV 


ToFticoKlis, 


Fig-  24 


TLATE   V 

IFallse  AioLcliLjldJsis  ©f  BSmee  Joint. 


rig-.  28, 


l^LATE   VI 


Lateral  CMrvaturice  . 


MEDICAL  PAPERS. 


DR.    BOWDITCH'S   "YOUNG   STETHOSCOPIST."i 

We  have  derived  much  pleasure  from  Dr.  Bowditch's  book. 
The  author  evidently  has  a  good  practical  estimate  of  the 
value  of  physical  exploration.  Instance  such  sentences  as 
these :  "  Do  not  trouble  yourself  so  much  about  nice  dis- 
tinctions of  sound,  but  observe  accurately,  first,  where  the 
sounds  are  heard,  second,  where  the  focus  of  them  is,  sup- 
posing that  they  exist  everywhere  in  both  lungs,  and,  third, 
their  combinations  with  other  physical  and  rational  signs." 
(p.  37.)  Again,  "It  is  of  no  importance  for  the  pupil  to 
trouble  himself  to  decide  definitely  whether  he  hears  bron- 
chophony, Eegophony,  or  the  various  kinds  of  pectoriloquy. 
It  is  sufficient  that,  on  a  comparison  between  the  lungs,  he 
finds  an  increased  or  diminished  natural  resonance  in  any 
part.  The  other  physical  and  rational  symptoms,  when  com- 
pared with  even  these  apparently  doubtful  signs,  will  enable 
him  to  arrive  at  a  correct  diagnosis."     (p.  29.) 

This  is  refreshing  after  the  refinements  of  Fournet  and 
Piorry.  It  is  truth  we  rarely  hear.  It  sums  up  questions 
commonly  left  for  the  student  to  decide,  but  which  he  cannot 
settle  until  he  has  waded  through  the  whole  tract  of  study. 
But  who  reads  through  Tweedie,  or  Middlemore,  or  Andral's 
Clinique,  or  Velpeau's  Surgery  ?  Who,  if  he  did,  could 
hold  all  the  facts  in  these  great  storehouses  ?  We  go  to 
market  for  them  when  we  are  in  want.  We  refer  to  them. 
We  furnish  our  own  books  and  lectures  from  them.     We 

1  A  Review,  from  the  Boston  Medical  and  Surgical  Journal,  March 
18,  1846. 

11 


162  DR.  BOWDITCH'S   "YOUNG  STETHOSCOPIST." 

draw  from  them  as  Johnson  did  from  other  books  to  write  a 
dictionary.  But  neither  did  he,  nor  do  the  authors  them- 
selves, nor  can  we,  retain  all  the  facts  these  books  include ; 
yet  we  should  be  sorry  to  avow  that  we  were  ignorant  of 
their  leading  principles.  There  is  something  to  be  got  at 
short  of  reading  mammoth  treatises,  and  it  is  precisely  this 
that  the  beginner  wants ;  he  wants  the  principles,  and  he 
gets  them  in  such  a  book  as  this  before  us.  Even  in  large 
works  medical  students  do  not  generally  ask  for  a  copious 
statement  of  facts,  or  a  wide  range  of  authorities ;  few  prac- 
titioners do;  they  have  not  time,  perhaps  inclination,  to  boil 
down  crudities  and  to  extract  their  valuable  principles.  It 
is  a  much  more  natural  division  of  labor  which  leaves  to  the 
student  only  the  care  of  digesting  the  material  which  some- 
body else  has  collected  and  prepared. 

In  this  culinary  capacity,  there  are  a  variety  of  ways  in 
which  medical  compilers  may  serve  up  original  or  other 
facts ;  and  it  is  a  nice  problem  to  prepare  this  intellectual 
food,  and  to  adapt  it  at  once  to  the  infancy  or  the  maturity  of 
its  consumers.  There  is  a  range  from  the  vade  mecum,  or 
portable  soup  style  which  presents  the  gist  of  the  matter 
in  its  most  concentrated  form,  to  the  potage  maigre,  diluted 
with  a  formal  statement  of  obvious  considerations,  and  the 
Julienne  or  Geaufret  of  Copland  or  Cooper  or  Ben.  Bell. 

Our  theory  is,  that  students  prefer  knowledge  in  its  con- 
centrated form.  First,  because  the  deglutition  is  facilitated. 
A  certain  mental  effort  attends  the  process  of  acquisition,  and 
this  effort,  if  simple,  convulsive,  and  brief,  is  more  salutary 
than  when  prolonged  till  it  fatigues.  And  much  of  medical 
knowledge  does  fatigue  the  student.  It  fails  to  captivate  the 
imagination.  It  is  more  useful  than  palatable.  It  goes  down 
easier  if  rolled  into  the  pill-like  sphericity  of  aphorisms. 
We  believe  it  is  natural  for  the  mind  to  require  knowledge 
in  this  condensed  form  before  it  proceeds  to  expand  it;  we 


DR.  BOWDITCH'S  "YOUNG  STETHOSCOPIST."  163 

want  the  corollary  before  the  demonstration,  the  hypothesis 
before  the  facts,  the  bill  of  fare  before  the  dinner.  We  re- 
quire to  know  what  kind  of  intellectual  accommodations  a 
given  subject  is  likely  to  exact,  before  we  proceed  to  take  it 
in.  A  subsequent  process  is  that  of  settling  things  into  their 
places,  of  digesting,  or  rather  of  ruminating;  and  when  the 
subject  is  thus  again  brought  up,  any  modification  or  addi- 
tion is  made  to  suit  the  taste  of  the  individual. 

Accordingly,  in  many  sciences,  especially  in  the  classifi- 
catory  sciences,  where  facts  are  numerous,  the  mind  has 
resorted  to  this  stenographic  mode  of  getting  possession  of 
all  that  is  most  important  before  it  indulges  the  imagina- 
tion with  interesting  detail  or  pleasant  associations."  Birds 
are  "  lobe-footed "  with  "  primaries  ash, "  and  leaves  are 
identified  as  "pinnate"  or  "pilose"  before  we  hear  of  their 
brilliant  colors  or  curious  habits.  Let  us  modify  such  a  de- 
scription to  illustrate  these  differences;  for  example, —  from 
Linnaeus :  The  plant  "  Geranium  maculatum.  .  .  .  Peduncles 
two-flowered ;  stem  forked,  erect,  leaves  five-parted  and  cut, 
the  two  upper  ones  sessile."  The  monograph  is  complete, 
and  enables  us  to  identify  the  plant.  Spreading  the  facts  a 
little  thinner,  we  might  say:  "This  interesting  plant  is 
found  both  in  the  woods  and  by  the  roadside.  Its  peduncles 
are  long  and  hairy,  commonly  supporting  two  flowers,  occa- 
sionally more.  The  stems  are  also  hairy,  erect,  dividing 
by  forks  or  more  numerous  branches."  Or,  modestly  in- 
troducing ourselves  to  the  reader,  after  the  manner  of  John 
Bell:  "I  really  consider  this  fine  plant  quite  as  attractive  as 
most  of  the  pampered  inhabitants  of  our  greenhouses.  With 
a  few  drops  of  moisture,  it  springs  from  the  soil,  and  I  have 
found  it  growing,  utterly  regardless  of  the  advantages  of  posi- 
tion, under  the  patronage  of  some  sturdy  old  fence,  or  on  the 
very  brink  of  an  awful  and  overwhelming  cataract." 

But  business  is  business.     Law  reports  do  not  tell  us  how 


164  DR.   BOWDITCH'S  "YOUNG  STETHOSCOPIST." 

Mrs.  Doakcs  felt  during  her  husband's  litigation,  nor  what 
the  lawyer  said  to  console  her.  Neither  do  we  want  to  know 
that  a  case  of  melanosis  was  respected  and  beloved,  nor  that 
the  doctor  was  called  in  or  anxious.  It  may  be  interesting, 
but  it  is  out  of  place.  It  belongs  to  the  affections,  not  the  in- 
tellect :  to  practice,  not  theory ;  to  society,  not  science ;  to  the 
individual,  not  the  profession.     We  want  the  naked  facts. 

We  are  all  aware  that  he  who  puts  two  things  together  and 
pleases  thfi  imagination  has  a  far  more  grateful  office  than 
he  who  reverses  the  process,  and  in  pointing  out  differences 
only  exercises  a  scientific  discrimination.  Besides,  imagi- 
nation is  a  gift;  it  excites  admiration,  and  we  are  insensibly 
moved  to  reward  it,  while  good  judgment  combined  with 
persevering  industry  will  make  anybody  an  average  scien- 
tist ;  it  affords  us  no  especial  pleasure ;  it  consequently  puts 
us  under  no  obligation,  and  it  is  very  apt  to  get  only  its 
"thwacks  and  thistles." 

We  believe  that  imagination  has  its  proper  office  in  sci- 
ence; but  it  should  be  heavily  ballasted  with  judgment. 
It  then  belongs  to  the  discoverer,  and  is  intended  for  the 
perception  of  real,  and  not  of  fanciful  or  poetical  resem- 
blances. It  may  also  amuse,  as  far  as  it  can,  without  sub- 
stituting the  entertaining  for  the  true.  But  we  hold  that 
there  are  at  least  two  classes  of  readers  who  prefer  a  concise 
statement  of  facts,  divested  of  ornament;  the  one  a  numerous 
body,  who  do  not  appreciate  efforts  of  the  imagination ;  the 
other,  those  who  when  they  seek  for  facts  do  not  look  for 
wit,  who  prefer  to  have  their  salt  kept  separate,  and  to  help 
themselves  to  it.  Of  this  number  are  most  medical  students ; 
they  want  little  imaginative  entertainment  in  their  medical 
grammars.  They  are  to  make  an  exertion,  to  toil  up  an 
elevation  bristling  with  new  facts.  Youth  has  activity,  but 
wind  and  dogged  bottom  are  the  prerogatives  of  maturity; 
it  is  obviously  easier  to  stride  over  a  vade  mecum  with  an 


DR.  BOWDITCH'S  "YOUNG  STETHOSCOPIST."  165 

occasional  clonic  spasm,  than  to  ascend  the  gently  inclined 
plane  of  some  flowery  but  protracted  octavo. 

Mere  imaginative  adulteration  is,  we  conceive,  still  more 
objectionable.  Without  alluding  to  the  caterers  of  irrelevant 
or  noxious  facts,  we  will  mention  one  common  way  of  impair- 
ing the  spirit  of  a  book;  of  reducing  its  proof.  It  presents 
old  things  as  new,  and  imparts  with  the  severity  of  science 
facts  which  possibly  are  new  in  their  medical  application,  but 
old  as  the  learner's  every-day  experience.  For  example, 
most  medical  students  are  familiar,  to  judge  from  the  devices 
upon  lecture-room  benches,  with  the  use  of  knives ;  and  yet, 
at  the  outset  of  operative  surgery,  the  student  must  learn 
anew  five  different  positions  of  holding  his  scalpel.  The 
crepitus  of  fracture  is  surgical  myth,  and  the  reduction  of  a 
dislocated  finger  is  described  in  pages ;  and  yet  it  sometimes 
happens  that  some  bystander  has  settled  the  question  of 
fracture,  or  has  pulled  a  bone  into  its  place  before  the  sur- 
geon arrives  upon  the  scene  of  accident.  We  venture  to 
affirm  that  no  practical  man  could  hear  an  amphoric  respira- 
tion without  feeling  sure  that  it  came  from  a  cavity.  Some- 
thing might  undoubtedly  be  added  to  this  popular  medical 
knowledge,  even  in  the  other  sex ;  but  it  seems  to  us  quite  as 
true  that  undue  weight  is  often  given  in  scientific  books  to 
medical  positions  which  are  truisms  in  every-day  non-medi- 
cal experience,  and  that  the  most  satisfactory  work  to  the 
student  is  that  which  passes  lightly  over  such  considerations, 
and  dwells  upon  medical  occurrences  which  do  not  happen 
as  his  general  experience  would  lead  him  to  expect. 

If  we  are  right,  students  at  first  need  only  the  important 
facts;  such  as  are  necessary  and  sufficient  to  a  "determi- 
native analysis  "  of  disease.  Nor  do  they  want  the  patho- 
logical biographies  of  individuals,  but  general  results  and 
model  cases,  —  type  cases,  succinct  and  portable,  to  which 
subsequent  exceptions  may  be  appended. 


166  DR.  BOWDITCH'S  "YOUNG  STETHOSCOPIST." 

We  remember  saying  to  a  well-known  French  writer,  who 
added  the  notes  to  the  French  edition  of  Hunter's  works, 
that  we  had  learned  much  with  little  labor  from  these  arti- 
cles condensed  into  aphorisms.  "Ah!"  replied  he,  "that 
style  would  make  books  scarce;  those  few  pages  contain 
matter  for  a  small  octavo." 

For  the  possession  of  this  kernel,  the  reader  is  ever  strug- 
gling with  the  author,  whose  instincts  would  bury  it  among 
octavo  pages ;  but  it  requires  great  practice  to  "  gut "  a 
book  quietly ;  with  most  readers  the  effort  becomes  harass- 
ing. Rostan,  with  French  hyperbole,  makes  it  fatal  to  both 
parties:  "L'auteur  se  tue  a  allonger  ce  que  le  lecteur  se 
tue  a  abreger. " 

With  these  politics  we  once  proposed  to  try  our  hand  at 
condensing  the  subject  of  Dr.  Bowditch's  book,  the  standard 
and  gage  of  compression  being  utility  in  every-day  practice. 
The  programme  passed  by  certain  points,  which,  like  the 
phenomena  of  succussion,  are  scientifically  interesting,  but 
comparatively  useless  because  they  indicate  lesions  already 
discovered  by  other  signs,  and  dwelt  on  certain  other  non- 
auscultatory  signs  and  symptoms  which  are  diagnostic  or 
pathognomonic.  These  often  occur:  there  are  cases  of  un- 
doubted tubercle  where  auscultation  tells  us  nothing;  and  we 
derive  our  knowledge  of  the  lesion  from  common  signs  and 
symptoms.  It  would  be  quite  as  annoying  to  be  here  out- 
diagnosed  by  one  behind  the  age  in  science  and  ignorant  of 
the  improved  method,  as  to  find  our  neighbor  succeeding 
with  a  pork  bait  while  we  were  attempting  the  fruitless 
mysteries  of  lancewood  and  red  hackles. 

We  once  thought  of  it;  but  Di\  Bowditch  occupies  the 
unoccupied  ground.  He  has  booked  Lacnnec  up  to  date,  and 
has  compressed  his  genius,  as  the  fisherman  in  the  Arabian 
Nights  did  his,  into  a  prodigiously  small  volume;  yet  it 
contains   separate    articles    upon   percussion,    common    and 


DR.  BOWDITCH'S  "YOUNG  STETHOSCOPIST."  167 

auscultatory ;  auscultation  thoracic,  fcetal,  cephalic,  and  ve- 
terinary; of  course  no  duplicate  specimens  nor  jactolites; 
but  all  the  regular  aggregations  of  the  books,  while  many 
original  and  floating  facts  are  crystallized  about  their 
appropriate  heads.  We  commend  it  to  auscultors  and  to 
non-auscultors. 


168  NEW  PHYSICAL  SIGN. 


NEW  PHYSICAL   SIGN.i 

This  is  a  rapid  ticking  sound  in  the  throat,  audible  across 
the  room,  invohmtary,  and  independent  of  circulation  or  of 
respiration, —  a  phenomenon  interesting  from  its  anomalous 
character  rather  than  its  diagnostic  value. 

The  subject  who  presents  this  curious  physical  sign  is  a 
rather  pretty  girl  of  seventeen,  small  in  stature,  and  of 
healthy  appearance, — Jane  McMurph}-,  of  Derry,  New  Hamp- 
shire. I  am  indebted  to  her  physician,  Dr.  Wallace,  for  the 
opportunity  to  examine  this  interesting  case. 

From  her  own  account,  which  is  here  subjoined,  her 
general  health  has  been  impaired  for  some  time  past.  Five 
years  ago  a  piece  of  tobacco  was  inserted  in  her  right  ear 
for  an  ear-ache  by  an  old  woman.  Of  this  piece  of  tobacco, 
the  patient  saw  no  more  at  that  time,  but  at  the  end  of  a 
month,  and  for  three  subsequent  months,  a  physician  made 
frequent  attempts  to  extract  it,  and  succeeded  on  one  occa- 
sion in  removing  what  was  said  to  be  a  fragment  of  tobacco. 
At  the  end  of  a  year  two  more  fragments  were  extracted, 
with  some  force,  after  the  use  of  a  caustic  or  ^'■hurning'^ 
liquid. 

During  this  year  the  pain  in  the  ear  and  right  side  of  the 
head  continued,  and  at  one  time  with  considerable  swelling 
in  the  region  of  the  parotid,  threatening,  as  her  physician 
stated,  to  open  and  discharge. 

During  three  subsequent  years  the  head  was  frequently 
painful, — the  pain  sometimes  darting,  at  other  times  sug- 
gesting the  sensation  of  cold  water  in  the    cavity  of  the 

»  The  Boston  Medical  and  Surgical  Journal,  Xovember  3,  1847. 


NEW  PHYSICAL  SIGN.  169 

crauium, —  these  symptoms,  chiefly  confined  to  the  right 
side,  being  occasionally  so  severe  as  to  make  the  patient 
cry,  and  even  confine  her  to  bed  several  days  at  a  time. 

In  March,  18-46,  the  right  side  of  the  face  swelled  as 
before,  the  tumefaction  occupying  chiefly  the  region  of  the 
cheek,  mastoid  process,  and  parotid.  While  lying  in  bed 
a  few  days  after  the  attack  the  patient  first  heard  this 
noise,  and  was  at  a  loss  to  account  for  it.  It  commenced 
suddenly,  somewhat  slower  than  at  present,  but  the  same 
in  character.  Since  then,  it  has  continued  with  little 
intermission.  There  has  been  no  discharge  from  the  ear 
other  than  that  following  the  violence  used  in  the  extraction 
of  the  supposed  foreign  body,  nor  has  the  hearing  been 
affected.  The  mastoid  region  has  been  at  times  universally 
tender,  and  now  presents  a  sensitive  point  a  quarter  of  an 
inch  in  diameter  at  about  its  centre,  though  the  pain  in  the 
head  during  the  last  year  has  been  comparatively  slight. 

A  person  sitting  in  the  same  room  with  this  patient  hears 
a  distant  muffled  sound,  which  might  easily  be  mistaken  for 
the  rapid  dropping  of  water  into  the  pail  of  a  closed  wash- 
stand.  An  idea  of  the  sound  may  be  conveyed  by  the  words 
clicTc,  clicJcj  elide,  or  occasionally  click-click,  click-click,  etc. 
Being  requested  to  open  her  mouth,  it  becomes  surpris- 
ingly distinct  and  audible,  and,  apparently  stimulated  by 
the  effort  or  by  the  contact  of  air,  the  ticking  becomes 
rapid,  sometimes  single,  sometimes  reduplicated,  irregular, 
pausing  for  an  instant,  then  giving  six  or  eight  explosions 
in  rapid  succession,  to  be  again  followed  by  pauses  and 
single  or  double  vibrations  as  before.  It  is  now  no  longer 
muffled,  but  sharp  and  distinct,  deriving  a  little  cavernous 
intonation  from  the  fauces  or  larynx,  but  otherwise  resem- 
bling the  snapping  of  the  finger-nails  or  of  a  quill  pen,  the 
distant  sound  of  castanets,  or,  which  is  a  better  comparison, 
the  irregular  clicking  of  the  electro-magnet  attached  to  the 


170  NEW  PHYSICAL  SIGN. 

telegraph,  to  which  it  was  very  happily  compared  by  my 
friend  Dr.  Gould.  All  this  while  the  patient  sits  quiet  and 
unmoved,  as  if  unconscious  of  anything  unusual.  It  is 
not  so,  however.  Upon  being  questioned,  she  refers  the 
seat  of  the  noise  to  a  spot  on  the  right  side  of  the  neck, 
near  the  summit  of  the  thyroid  cartilage,  and  upon  it.  This 
is  discovered  by  the  touch,  and  by  the  stethoscope,  to  be  the 
maximum  of  the  vibration.  The  noise  can  be  stopped  by 
pressing  upon  this  point  so  as  to  displace  the  larynx.  The 
patient  describes  a  sensation  of  "drawing"  when  the  chin 
is  carried  to  the  left,  and  of  "  something  running  into  "  or 
penetrating  the  tissues  when  the  chin  is  carried  to  the  right, 
so  as  to  compress  the  region.  But  besides  this,  and  a  con- 
siderable "soreness"  which  exists  in  the  neighborhood,  she 
experiences  no  inconvenience  from  the  noise. 

Internally  the  fauces  are  red;  and  here  an  important 
feature  of  the  case  is  found.  The  uvula  is  alternately 
and  spasmodically  retracted  and  relaxed  synchronously  with 
the  explosions;  sometimes  four  or  five  times  in  a  second. 
This  spasmodic  muscular  action  is  extended  to  the  soft 
palate  and  to  the  pillar  of  the  right  side,  and  the  whole 
appearance  is  such  that  in  looking  for  the  first  time  into  the 
throat  all  difficulty  in  the  diagnosis  seems  to  be  at  an  end. 
The  sound  appears  to  come  from  the  soft  palate.  Yet  I 
think  this  is  not  its  real  source.  The  uvula  can  be  seized 
and  drawn  forward,  and  the  soft  palate  may  be  compressed 
against  the  vertebral  column,  and  the  noise  goes  on;  less 
rapidly,  to  be  sure,  but  I  think  unequivocally.  Besides,  the 
maximum  of  the  sound  is  not  in  this  region. 

Upon  depressing  the  tongue,  the  epiglottis  is  brought 
into  view  rather  low  down,  but  motionless  while  the  noise 
continues. 

What,  then,  is  the  source  of  the  sound  ?  First,  as  regards 
its  seat.     This  seems  to  be  at  the  point  already  described; 


NEW  PHYSICAL  SIGN.  171 

viz.  just  below  the  summit  of  the  thyroid  cartilage  on  the 
right  side.  Secondly,  the  motor  power  is  apparently  a  spas- 
modic action  of  the  muscles  in  the  neighborhood  of  the  fauces 
or  larynx,  —  an  action  analogous  to  that  of  chorea.  On  the 
other  hand,  it  is  very  likely  that  the  spasmodic  action  is 
induced  by  the  irritation  of  the  neighboring  bone,  if  it  be 
diseased.  Thirdly,  as  to  the  proximate  mechanism  of  the 
sound.  This,  the  chief  interest  in  the  case,  is  unfortunately 
of  doubtful  origin.  Two  mechanical  combinations,  and 
only  two,  appear  to  me  sufficient  to  produce  an  occurrence 
of  this  nature.  Of  these,  one  is  the  rapid  passing  and  repass- 
ing of  two  hard  surfaces  in  contact  with  each  other,  like  the 
movement  by  which  the  finger  and  thumb  nail  are  snapped 
together.  Broken  portions  of  the  os  hyoides,  or  of  an  ossi- 
fied cartilage,  might  also  produce,  by  the  aid  of  the  muscles, 
a  crepitus  of  this  anomalous  character-  Yet  it  is  proba- 
ble that  the  impinging  fragments  would  be  worn  smooth  in 
time,  and  the  sound  thus  modified.  At  any  rate  there  is  no 
discoverable  discharge  of  pus  or  blood  which  would  accom- 
pany fracture  or  necrosis  in  this  region.  The  evidence  is 
against  such  a  condition  of  the  parts. 

The  other  explanation  of  the  sound  lies  in  an  alternate 
opening  and  closure  of  the  moist  mouth  of  a  sac,  by  which  a 
bubble  of  air  is  expelled  at  each  contraction,  and  a  bubble 
sucked  in  at  each  dilation  of  its  cavity.  Such  a  sac  exists 
between  the  vocal  cords,  or  might  be  formed  at  one  extrem- 
ity of  the  OS  hyoides,  with  a  fistulous  opening. 

Of  these  two  possible  causes,  the  former  seems  to  be,  on 
the  whole,  the  more  probable,  though  the  extreme  distinct- 
ness and  the  force  of  the  explosions,  and  above  all  their  great 
rapidity,  render  it  difficult  to  accept  its  supposition. 

Such  a  solution  of  the  cause  of  this  singular  phenomenon 
is  far  from  satisfactory,  yet  it  is  difficult  to  adduce  any  addi- 
tional evidence  of  its  nature.     The  patient  was  examined  by 


172  NEW  PHYSICAL  SIGN. 

many  medical  gentlemen  before  and  during  her  visit  to 
Boston,  both  at  the  Hospital  and  at  the  Society  for  Medical 
Improvement,  to  whom  I  presented  the  case. 

In  relation  to  the  medical  treatment  to  which  the  patient 
has  been  subjected,  it  may  be  stated  that  before  her  entrance 
into  the  Hospital  a  great  variety  of  tentative  remedies  had 
been  adopted.  Among  them  were  a  course  of  electricity 
during  seven  weeks, —  two  setons  of  five  and  seven  weeks 
respectively, —  blisters,  leeches,  iodine,  and  internal  local 
cauterization, —  all  without  effect.  An  external  application 
of  the  ointment  of  veratria  suspended  the  spasmodic  action, 
and  also  the  noise,  during  a  number  of  hours,  when  it  again 
recurred.  During  her  residence  in  the  Hospital,  I  deemed 
it  unnecessary  to  harass  the  patient  by  repeating  applications 
which  seem  to  have  been  faithfully  tried;  and  the  patient 
has  been  altogether  unwilling  to  submit  to  the  division  of 
one  of  the  pillars  of  the  palate  which  I  proposed  to  her.  If 
the  spasmodic  contraction  can  be  considered  to  partake  of 
the  nature  of  chorea,  the  age  of  the  patient  renders  a  spon- 
taneous termination  of  the  affection  not  improbable.  On  the 
other  hand,  if  it  be  provoked  by  any  inflammatory  state  of 
the  hard  parts,  it  will  not  improbably  subside  when  this 
affection,  which  seems  to  be  diminishing,  shall  disappear. 


CASE  OF  INJURY  OF  HEAD.  173 


CASE  OF   INJURY   OF  HEAD.i 

The  following  case,  perhaps  unparalleled  in  the  annals  of 
surgery,  and  of  which  some  interesting  details  have  already 
been  published,  occurred  in  the  practice  of  Dr.  J.  M.  Har- 
low, of  Cavendish,  Vermont.  Having  received  a  verbal 
account  of  the  accident  a  few  days  after  its  occurrence 
from  a  medical  gentleman  who  had  examined  the  patient, 
I  thus  became  incidentally  interested  in  it;  and  having 
since  had  an  opportunity,  through  the  politeness  of  Dr.  Har- 
low, of  observing  the  patient,  who  remained  in  Boston  a 
number  of  weeks  under  my  charge,  I  have  been  able  to 
satisfy  myself  as  well  of  the  occurrence  and  extent  of  the 
injury  as  of  the  manner  of  its  infliction.  I  am  also  indebted 
to  the  same  gentleman  for  procuring  at  my  request  the 
testimony  of  a  number  of  persons  who  were  cognizant  of  the 
accident  or  its  sequel. 

Those  who  are  sceptical  in  admitting  the  coexistence  of  a 
lesion  so  grave  with  an  inconsiderable  disturbance  of  func- 
tion, will  be  interested  in  further  details  connected  with  the 
case ;  while  it  is  due  to  science  that  a  complete  record  should 
be  made  of  the  history  of  so  remarkable  an  injury. 

The  accident  occurred  upon  the  line  of  the  Rutland  and 
Burlington  Railroad,  on  the  13th  of  September,  1848.  The 
subject  of  it,  Phineas  P.  Gage,  is  of  middle  stature,  twenty- 
five  years  of  age,  shrewd  and  intelligent.  According  to  his 
own  statement,  he  was  charging  with  powder  a  hole  drilled 

^  From  the  American  Journal  of  the  Medical  Sciences,  July,  1850, 
entitled  "  Dr.  Harlow's  Case  of  Recovery  from  the  Passage  of  an  Iron 
Bar  through  the  Head." 


174  CASE   OF  INJURY  OF   HEAD. 

in  a  rock  for  the  purpose  of  blasting.  It  appears  that  it  is 
customary  in  charging  the  hole  to  cover  the  powder  with 
sand.  In  this  case,  the  charge  having  been  adjusted,  Mr. 
Gage  directed  his  assistant  to  pour  in  the  sand;  and  at  the 
interval  of  a  few  seconds,  his  head  being  averted,  and  suppos- 
ing the  sand  to  have  been  properly  placed,  he  dropped  the 
head  of  a  tamping  iron  as  usual  upon  the  charge,  to  consoli- 
date or  "tamp  it  in."  The  assistant  had  failed  to  obey  the 
order,  and,  the  iron  striking  fire  upon  the  rock,  the  uncovered 
powder  was  ignited,  and  an  explosion  took  place.  Mr.  Gage 
Avas  at  this  time  standing  above  the  hole,  leaning  forward, 
with  his  face  slightly  averted ;  and  the  bar  of  iron  was  pro- 
jected directly  upward  in  the  line  of  its  axis,  passing  com- 
pletely through  his  head  and  high  into  the  air.  The  wound 
thus  received,  and  which  is  more  fully  described  in  the 
sequel,  was  oblique,  traversing  the  cranium  in  a  straight  line 
from  the  angle  of  the  lower  jaw  on  one  side  to  the  centre 
of  the  frontal  bone  above,  near  the  sagittal  suture,  where  the 
missile  emerged ;  and  the  iron  thus  forcibly  thrown  into  the 
air  was  picked  up  at  a  distance  of  some  rods  from  the  pa- 
tient, smeared  with  brains  and  blood. 

From  this  extraordinary  lesion  the  patient  has  quite  recov- 
ered in  his  faculties  of  body  and  mind,  excepting  only  the 
loss  of  the  sight  of  one  eye. 

The  iron  which  thus  traversed  the  skull  weighs  thirteen 
and  a  quarter  pounds.  It  is  three  feet  seven  inches  in  length, 
and  one  and  a  quarter  inches  in  diameter.  The  end  which 
entered  first  is  pointed,  the  taper  being  seven  inches  long, 
and  the  diameter  of  the  point  one  quarter  of  an  inch, — 
circumstances  to  which  the  patient  perhaps  owes  his  life. 
The  iron  is  unlike  any  other,  and  was  made  by  a  neighbor- 
ing blacksmith  to  please  the  fancy  of  the  owner. 

Dr.  Harlow,  in  the  graphic  account  above  alluded  to,  states 
that  "  immediately  after  the  explosion  the  patient  was  thrown 


CASE  OF  INJURY  OF  HEAD.  175 

upon  his  back,  and  gave  a  few  convulsive  motions  of  the 
extremities,  but  spoke  in  a  few  minutes.  His  men  (with 
whom  he  was  a  great  favorite)  took  him  in  their  arms  and 
carried  him  to  the  road,  only  a  few  rods  distant,  and  put 
him  into  an  ox  cart,  in  which  he  rode,  sitting  erect,  full 
three  quarters  of  a  mile,  to  the  hotel  of  Mr.  Joseph  Adams, 
in  this  village.  He  got  out  of  the  cart  himself,  and  with  a 
little  assistance  walked  up  a  long  flight  of  stairs  into  the 
hall,  where  his  wounds  were  dressed." 

Mr.  Joseph  Adams,  here  spoken  of,  has  furnished  the  fol- 
lowing interesting  statement :  — 

This  is  to  certify  that  P.  P.  Gage  had  boarded  in  my  house  for 
several  weeks  previous  to  his  being  injured  upon  the  railroad, 
and  that  I  saw  him  and  conversed  with  him  soon  after  the  acci- 
dent, and  am  of  opinion  that  he  was  perfectly  conscious  of  what 
was  passing  around  him.  He  rode  to  the  house,  three  quarters 
of  a  mile,  sitting  in  a  cart,  and  walked  from  the  cart  to  the 
piazza,  and  thence  up  stairs,  with  but  little  assistance.  I  noticed 
the  state  of  the  left  eye,  and  know  from  experiment  that  he  could 
see  with  it  for  several  days,  though  not  distinctly.  In  regard  to 
the  elevated  appearance  of  the  wound,  and  the  introduction  of 
the  finger  into  it,  I  can  fully  confirm  the  certificate  of  my  nephew, 
Washington  Adams,  and  others,  and  would  add  that  I  repeatedly 
saw  him  eject  matter  from  the  mouth  similar  in  appearance  to 
that  discharged  from  the  head.  The  morning  subsequent  to  the 
accident  I  went  in  quest  of  the  bar,  and  found  it  at  a  smith's  shop, 
near  the  pit  in  which  he  was  engaged. 

The  men  in  his  pit  asserted  that  "  they  found  the  iron  covered 
with  blood  and  brains,"  several  rods  behind  where  Mr.  Gage 
stood,  and  that  they  washed  it  in  the  brook  and  returned  it  with 
the  other  tools ;  which  representation  was  fully  corroborated  by 
the  greasy  feel  and  look  of  the  iron,  and  the,  fragmeiits  of  brain 
which  I  saiv  upon  the  rock  where  it  fell. 

Joseph  Adams, 

Justice  of  the  Peace. 
Cavendish,  December  14,  1849. 


176  CASE  OF  INJURY  OF  HEAD. 

The  Rev.  Joseph  Freeman,  whose  letter  follows,  informed 
himself  of  the  circumstances  soon  after  the  accident. 

Cavendish,  December,  5,  1849. 

Dear  Sir,  —  I  was  at  home  on  the  day  Mr.  Gage  was  hurt ; 
and  seeing  an  Irishman  ride  rapidly  up  to  your  door,  I  stepped 
over  to  ascertain  the  cause,  and  then  went  immediately  to  meet 
those  who  I  was  informed  were  bringing  him  to  our  village. 

I  found  him  in  a  cart,  sitting  up  without  aid,  with  his  back 
against  the  foreboard.  When  we  reached  his  quarters,  he  rose 
to  his  feet  without  aid  and  walked  quick,  though  with  an  un- 
steady step,  to  the  hind  end  of  the  cart,  when  two  of  his  men 
came  forward  and  aided  him  out,  and  walked  with  him,  support- 
ing him  to  the  house. 

I  then  asked  his  men  how  he  came  to  be  hurt  ?  The  reply 
was,  "  The  blast  went  off  when  he  was  tamping  it,  and  the  tamp- 
ing-iron  passed  through  his  head."     I  said,  "  That  is  impossible." 

Soon  after  this,  I  went  to  the  place  where  the  accident  hap- 
pened. I  found  upon  the  rocks,  where  I  supposed  he  had  fallen, 
a  small  quantity  of  brains.  There  being  no  person  at  this  place, 
I  passed  on  to  a  blacksmith's  shop  a  few  rods  beyond,  in  and 
about  which  a  number  of  Irishmen  were  collected.  As  I  came 
up  to  them,  they  pointed  me  to  the  iron  which  has  since  attracted 
so  much  attention,  standing  outside  the  shop  door.  They  said 
they  found  it  covered  with  brains  and  dirt,  and  had  washed  it 
in  the  brook.  The  a'ppearance  of  the  iron  corresponded  with  this 
story.     It  had  a  greasy  appearance,  and  was  so  to  the  touch. 

After  hearing  their  statement,  as  there  was  no  assignable  mo- 
tive for  misrepresentation,  and  finding  the  appearance  of  the  iron 
to  agree  with  it,  I  was  compelled  to  believe,  though  the  result  of 
your  examination  of  the  wound  was  not  then  known  to  me. 

I  think  of  nothing  further  relating  to  this  affair  which  cannot 
be  more  minutely  stated  by  others. 

Very  respectfully  yours, 

Joseph  Freeman. 
Dr.  J.  M.  Harlow. 

Dr.  Williams  first  saw  the  patient,  and  makes  the  follow- 
ino;  statement  in  relation  to  the  circumstances :  — 


CASE   OF  INJURY  OF  HEAD.  177 

NoRTHFiELu,  VERMONT,  December  4,  1849. 

Dear  Sir,  —  Dr.  Harlow  having  requested  me  to  transmit  to 
you  a  description  of  the  appearance  of  Mr.  Gage  at  the  time  I 
first  saw  him  after  the  accident,  which  happened  to  him  in  Sep- 
tember, 1848,  I  now  hasten  to  do  so  with  pleasure. 

Dr.  Harlow  being  absent  at  the  time  of  the  accident,  I  was 
sent  for,  and  was  the  first  physician  who  saw  Mr.  Gage,  some 
twenty-five  or  thirty  minutes  after  he  received  the  injury;  he  at 
that  time  was  sitting  in  a  chair  upon  the  piazza  of  Mr.  Adams's 
hotel  in  Cavendish.  When  I  drove  up,  he  said,  ''  Doctor,  here  is 
business  enough  for  you."  I  first  noticed  the  wound  upon  the 
head  before  I  alighted  from  my  carriage,  the  pulsations  of  the 
brain  being  very  distinct.  There  was  also  an  appearance  which, 
before  I  examined  the  head,  I  could  not  account  for :  the  top  of  the 
head  having  a  shape  somewhat  like  an  inverted  funnel ;  this  was 
owing,  I  discovered,  to  the  bone  being  fractured  about  the  open- 
ing for  a  distance  of  about  two  inches  in  every  direction.  I  ought 
to  have  mentioned  above  tliat  the  opening  through  the  skull  and 
integuments  was  not  far  from  one  and  a  half  inches  in  diameter; 
the  edges  of  this  opening  were  everted,  and  the  whole  wound 
appeared  as  if  some  wedge-shaped  body  had  passed  from  below  up- 
ward. Mr.  Gage  during  the  time  I  was  examining  this  wound  was 
relating  the  manner  in  which  he  was  injured  to  the  bystanders ; 
he  talked  so  rationally  and  was  so  willing  to  answer  questions  that 
I  directed  my  inquiries  to  him  in  preference  to  the  men  who  were 
with  hira  at  the  time  of  the  accident,  and  who  were  standing 
about  at  this  time.  Mr.  Gage  then  related  to  me  some  of  the 
circumstances,  as  he  has  since  done;  and  I  can  safely  say  that 
neither  at  that  time  nor  on  any  subsequent  occasion,  save  once, 
did  I  consider  him  to  be  otherwise  than  perfectly  rational.  The 
one  time  to  which  I  allude  was  about  a  fortnight  after  the  acci- 
dent, and  then  he  persisted  in  calling  me  John  Kirwin ;  yet  he 
answered  all  my  questions  correctly. 

I  did  not  believe  Mr.  Gage's  statement  at  that  time,  but  thought 
he  was  deceived;  I  asked  him  where  the  bar  entered,  and  he 
pointed  to  the  wound  on  his  cheek,  which  I  had  not  before  dis- 
covered ;  this  was  a  slit  running  from  the  angle  of  the  jaw  for- 
ward about  one  inch  and  a  half;  it  was  very  much  stretched 
laterally,  and  was  discolored  by  powder  and  iron  rust,  or  at  least 

12 


178  CASE   OF   INJURY    OF  HEAD. 

appeared  so.  Mr.  Gage  persisted  in  saying  that  the  bar  went 
through  his  head.  An  Irishman  standing  by  said,  "Sure  it  was 
so,  sir,  for  the  bar  is  lying  in  the  road  below,  all  blood  and 
brains."  The  man  also  said  he  would  have  brought  it  up  with 
him,  but  he  thought  there  would  be  an  inquest,  and  it  would 
not  do. 

About  this  time,  Mr.  Gage  got  up  and  vomited  a  large  quantity 
of  blood,  together  with  some  of  his  food ;  the  effort  of  vomiting 
pressed  out  about  half  a  teacupful  of  the  brain,  which  fell  upon 
the  floor,  together  with  the  blood,  which  was  forced  out  at  the 
same  time.  The  left  eye  appeared  more  dull  and  glassy  than  the 
right.     He  said  he  could  merely  distinguish  light  with  it. 

Soon  after  Dr.  Harlow  arrived,  Mr.  Gage  walked  up  stairs,  with 
little  or  no  assistance,  and  laid  down  upon  a  bed.  Dr.  Harlow 
made  a  thorough  examination  of  the  wounds,  passing  the  whole 
length  of  his  forefinger  into  the  superior  opening  without  diffi- 
culty; and  my  impression  is  that  he  did  the  same  with  the  in- 
ferior one,  but  of  that  I  am  not  absolutely  certain;  after  this  we 
proceeded  to  dress  the  wounds  in  the  manner  described  by  Dr. 
Harlow  in  the  Journal.  During  the  time  occupied  in  dressing, 
Mr.  Gage  vomited  two  or  three  times  fully  as  freely  as  before.  All 
of  this  time  he  was  perfectly  conscious,  answering  all  questions, 
and  calling  his  friends  by  name  as  they  came  into  the  room. 

I  did  not  see  the  bar  that  night,  but  saw  it  the  next  day  after 
it  was  washed. 

Hoping  you  will  excuse  this  hasty  sketch,  I  remain  yours,  etc. 

Edward  H.  Williams,  M.  D. 
Dr.  H.  J.  BiGELOw. 

Dr.  Harlow's  account  of  his  first  visit  to  the  patient,  and 
of  the  subsequent  symptoms,  is  here  appended. 

"Being  absent,  I  did  not  arrive  at  the  scene  of  the  accident 
until  near  six  o'clock,  p.  m.  You  will  excuse  me  for  remarking 
here  that  the  picture  presented  was,  to  one  unaccustomed  to  mili- 
tary surgery,  truly  terrific;  but  the  patient  bore  his  sufferings 
with  the  most  heroic  firmness.  He  recognized  me  at  once,  and 
said  he  hoped  he  was  not  much  hurt.  He  seemed  to  be  perfectly 
conscious,  but  was  getting  exhausted  from  the  hemorrhage,  which 


CASE  OF  INJURY  OF   HEAD.  179 

was  very  profuse  both  externally  and  internally,  the  blood  find- 
ing its  way  into  the  stomach,  which  rejected  it  as  often  as  every 
fifteen  or  twenty  minutes.  Pulse  sixty,  and  regular.  His  person 
and  the  bed  on  which  he  was  laid  were  literally  one  gore  of 
blood.  Assisted  by  my  friend,  Dr.  Williams  of  Proctorsville, 
who  was  first  called  to  the  patient,  we  proceeded  to  dress  the 
wounds.  From  their  appearance,  the  fragments  of  bone  being 
uplifted  and  the  brain  protruding,  it  was  evident  that  the  frac- 
ture was  occasioned  by  some  force  acting  from  below  upward. 
The  scalp  was  shaven,  the  coagula  removed,  together  with  three 
small  triangular  pieces  of  the  cranium,  and  in  searching  to  ascer- 
tain if  there  were  other  foreign  bodies  there,  I  passed  in  the  in- 
dex finger  its  whole  length,  without  the  least  resistance,  in  the 
direction  of  the  wound  in  the  cheek  which  received  the  other 
finger  in  like  manner.  A  portion  of  the  anterior  superior  angle 
of  each  parietal  bone,  and  a  semicircular  piece  of  the  frontal 
bone  were  fractured,  leaving  a  circular  opening  of  about  three 
and  a  half  inches  in  diameter.  This  examination,  and  the  ap- 
pearance of  the  iron,  which  was  found  some  rods  distant  smeared 
with  brain,  together  with  the  testimony  of  the  workmen,  and  of 
the  patient  himself,  who  was  still  sufficiently  conscious  to  say 
that  'the  iron  struck  his  head  and  passed  through,'  was  consid- 
ered at  the  time  conclusive  not  only  of  the  nature  of  the  accident, 
but  of  the  manner  in  which  it  occurred. 

"  I  have  been  asked  why  I  did  not  pass  a  probe  through  the 
entire  extent  of  the  wound  at  the  time.  I  think  no  surgeon  of 
discretion  would  have  upheld  me  in  the  trial  of  such  a  foolhardy 
experiment,  in  the  risk  of  disturbing  lacerated  vessels,  from  which 
the  hemorrhage  was  near  being  stanched,  and  thereby  rupturing 
the  attenuated  thread  by  which  the  sufferer  still  held  to  life. 
You  will  excuse  me  for  being  thus  particular,  inasmuch  as  I  am 
aware  that  the  nature  of  the  injury  has  been  seriously  ques- 
tioned by  many  medical  men  for  whom  I  entertain  a  very  high 
respect. 

"The  spicula  of  bone  having  been  taken  away,  a  portion  of 
the  brain,  which  hung  by  a  pedicle,  was  removed,  the  larger 
pieces  of  bone  replaced,  the  lacerated  scalp  brought  together 
as  nearly  as  possible  and  retained  by  adhesive  straps,  excepting 
at  the  posterior  angle,  and  over  this  a  dressing  of  compress,  night- 


180  CASE  OF  INJURY  OF  HEAD. 

cap,  and  roller  were  placed.  The  wound  in  the  face  was  left 
patulous,  covered  only  by  a  simple  dressing.  The  hands  and  fore- 
arms, both  deeply  burned  nearly  to  the  elbows,  were  dressed,  and 
the  patient  was  left  with  the  head  elevated,  and  the  attendants 
were  requested  to  keep  him  in  that  position. 

"  10  p.  M.,  same  evening.  The  dressings  are  saturated  with 
blood,  but  the  hemorrhage  appears  to  be  abating.  Has  vomited 
twice  only  since  being  dressed.  Sensorial  powers  remain  as 
yet  unimpaired.  Says  he  does  not  wish  to  see  his  friends, 
as  he  shall  be  at  work  in  a  day  or  two.  Tells  where  they 
live,  their  names,  etc.  Pulse  65;  constant  agitation  of  the 
lower  extremities. 

"September  14,  7  a.  m.  Has  slept  some  ;  appears  to  be  in  pain ; 
speaks  with  difficulty ;  tumefaction  of  face  considerable,  and  in- 
creasing;  pulse  70;  knows  his  friends  and  is  rational.  Asks 
who  is  foreman  in  his  pit.  Hemorrhage  internally  continues 
slightly.     Has  not  vomited  since  12  p.  m. 

"  September  15,  9  a.  m.  Has  slept  well  half  the  night.  Sees 
objects  indistinctly  with  the  left  eye  when  the  lids  are  sepa- 
rated. Hemorrhage  has  ceased;  pulse  70.  —  8  p.  m.  Restless  and 
delirious;  talks  much,  but  disconnected  and  incoherent;  pulse  84 
and  full.  Prescribed  wine  of  colchicum,  fSss  every  six  hours, 
until  it  purges  him.     Removed  the  nightcap. 

''September  16,  8  a.  m.  Patient  appears  more  quiet;  pulse  70. 
Dressed  the  wounds,  which  in  the  head  have  a  fetid  sero-purulent 
discharge,  with  particles  of  brain  intermingled.  No  discharge 
from  bowels.  Ordered  sulphate  of  magnesia,  §j,  repeated  every 
four  hours  until  it  operates.  Iced  water  to  the  head  and  eye.  A 
fungus  appears  at  the  external  canthus  of  the  left  eye.  Saj's 
the  left  side  of  his  head  is  banked  up. 

"  September  17,  8  a.  m.  Pulse  84.  Purged  freely.  Rational, 
and  knows  his  friends.  Discharge  from  the  brain  profuse,  very 
fetid  and  sanious.     Wounds  in  face  healing. 

"  September  18,  9  a.  m.  Slept  well  all  night,  and  lies  upon  his 
right  side.  Pulse  72;  tongue  red  and  dry;  breath  fetid.  Re- 
moved the  dressings,  and  passed  a  probe  to  the  base  of  the 
cranium,  without  giving  pain.  Ordered  a  cathartic,  which  oper- 
ated freely.  Cold  to  the  head.  Patient  says  he  shall  recover. 
He  is  delirious,  with  lucid  intervals. 


CASE   OF   INJURY   OF   HEAD.  181 

"September  19,  8  p.  m.  Has  been  very  restless  during  the  day; 
skin  hot  and  dry;  tongue  red;  excessive  thirst;  delirious,  talking 
incoherently  with  himself,  and  directing  his  men. 

"  September  20  and  21.     Has  remained  much  the  same. 

"  September  22,  8  a.  m.  Patient  has  had  a  very  restless  night. 
Throws  his  hands  and  feet  about,  and  tries  to  get  out  of  bed. 
Head  hot.  Says  he  shall  not  live  long  so.  Ordered  a  cathartic 
of  calomel  and  rhubarb,  to  be  followed  by  castor  oil,  if  it  does 
not  operate  in  six  hours.  —  4  p.  m.  Purged  freely  twice,  and  in- 
clines to  sleep. 

"  September  23.  Rested  well  most  of  the  night,  and  appears 
stronger  and  more  rational.  Pulse  80.  Shaved  the  scalp  a  second 
time,  and  brought  the  edges  of  the  wound  in  position,  the  original 
edges  having  sloughed  away.  Discharge  less  in  quantity  and  less 
fetid.     Loss  of  vision  of  left  eye. 

"From  this  time  until  the  3d  of  October  he  lay  in  a  semi- 
comatose state,  seldom  speaking  unless  spoken  to,  and  then  an- 
swering only  in  monosyllables.  During  this  period  fungi  started 
from  the  brain,  and  increased  rapidly  from  the  orbit.  To  these 
nitrate  of  silver  was  applied,  and  cold  to  the  head  generally. 
The  dressings  were  renewed  three  times  in  every  twenty-four 
hours ;  and  in  addition  to  this,  laxatives  combined  with  an  occa- 
sional dose  of  calomel  constituted  the  treatment.  The  pulse 
varied  from  70  to  96,  —  generally  very  soft.  During  this  time  an 
abscess  formed  under  the  frontalis  muscle,  which  was  opened  on 
the  27th,  and  has  been  very  difficult  to  heal.  Discharged  nearly 
eight  ounces  at  the  time  it  was  punctured. 

"October  5  and  6.  Patient  improving.  Discharge  from  the 
wound  and  sinus,  laudable  pus.  Calls  for  his  pants,  and  wishes 
to  get  out  of  bed,  though  he  is  unable  to  raise  his  head  from  the 
pillow. 

"October  7.  Has  succeeded  in  raising  himself  up,  took  one 
step  to  his  chair,  and  sat  about  five  minutes. 

"October  11.  Pulse  72.  Intellectual  faculties  brightening. 
When  I  asked  him  how  long  since  he  was  injured,  he  replied 
'Four  weeks  this  afternoon,  at  half  past  four  o'clock.'  Relates 
the  manner  in  which  the  accident  occurred,  and  how  he  came  to 
the  house.  He  keeps  the  day  of  the  week  and  time  of  day  in  his 
mind.     Says  he  knows  more  than  half  of  those  who  inquire  after 


182  CASE   OF   INJURY   OF   HEAD. 

him.  Does  not  estimate  size  or  money  accurately,  though  he  has 
memory  as  perfect  as  ever.  He  would  not  take  one  thousand 
dollars  for  a  few  pebbles  which  he  took  from  an  ancient  river  bed 
where  he  was  at  work.  The  fungus  is  giving  way  under  the  use 
of  the  nitrate  of  silver.  During  all  of  this  time  there  has  been  a 
discharge  of  pus  into  the  fauces,  a  part  of  which  passed  into  the 
stomach,  the  remainder  being  ejected  from  the  mouth. 

"October  20.  Improving.  Gets  out  and  into  bed  with  but 
little  assistance.  Sits  up  thirty  minutes  twice  in  twenty-four 
hours.  Is  very  childish ;  washes  to  go  home  to  Lebanon,  N.  H. 
The  wound  in  the  scalp  is  healing  rapidly. 

"November  8.  Improving  in  every  particular,  and  sits  up 
most  of  the  time  during  the  day.  Appetite  good,  though  he  is 
still  kept  upon  a  low  diet.  Pulse  do.  Sleeps  well,  and  says  he 
has  no  pain  in  the  head.  Food  digests  easily,  bowels  regular, 
and  nutrition  is  going  on  well.  The  sinus  under  the  frontalis 
muscle  has  nearly  healed.  He  walks  up  and  down  stairs,  and 
about  the  house,  into  the  piazza,  and  I  am  informed  this  evening 
that  he  has  been  in  the  street  to-day.  —  I  leave  him  for  a  week, 
with  strict  injunctions  to  avoid  excitement  and  exposure. 

"  November  15.  I  learn  on  inquiry  that  Gage  has  been  in  the 
street  every  day  except  Sunday  during  my  absence.  His  desire 
to  be  out  and  to  go  home  to  Lebanon  has  been  uncontrollable  by 
his  friends,  and  he  has  been  making  arrangements  to  that  effect. 
Yesterday  he  walked  half  a  mile,  and  purchased  some  small 
articles  at  the  store.  The  atmosphere  was  cold  and  damp,  the 
ground  wet,  and  he  went  without  an  overcoat,  and  with  thin 
boots.  He  got  wet  feet  and  a  chill.  I  find  him  in  bed,  depressed 
and  very  irritable.  Hot  and  dry  skin;  thirst,  tongue  coated; 
pulse  110 ;  lancinating  pain  in  left  side  of  head  and  face ;  rigors, 
and  bowels  constipated.  Ordered  cold  to  the  head  and  face,  and 
a  black  dose,  to  be  repeated  in  six  hours  if  it  does  not  operate. 
He  has  had  spicula  of  bone  pass  into  the  fauces,  which  he  ex- 
pelled from  the  mouth  within  a  few  days. 

"  November  16,  a.  m.  No  better.  Cathartic  has  operated  freely. 
Pulse  120 ;  skin  hot  and  dry ;  thirst  and  pain  remain  the  same. 
Has  been  very  restless  during  the  night.  Venesection  sixteen 
ounces.  Ordered  calomel,  ten  grains,  and  ipecac,  two  grains, 
followed  in  four  hours  by  castor  oil. 


CASE   OF   INJURY  OF   HEAD.  183 

"8  p.  M.,  same  day.  Purged  freely;  pulse  less  frequent;  pain 
in  head  moderated ;  skin  moist.  R.  Antim.  et  potass,  tart.,  three 
grains;  syr.  simplicis,  six  ounces.  Dose  a  dessert-spoonful  every 
four  hours. 

"November  17.  Improving.  Expresses  himself  as  feeling 
better  in  every  respect;  has  no  pain  in  the  head. 

"November  18.  Is  walking  about  the  house  again;  says  he 
feels  no  pain  in  the  head,  and  appears  to  be  in  a  way  of  recover- 
ing if  he  can  be  controlled." 

The  leading  feature  of  this  case  is  its  improbability.  A 
physician  who  holds  in  his  hand  a  crowbar,  three  feet  and  a 
half  long  and  more  than  thirteen  pounds  in  weight,  will 
not  readily  believe  that  it  has  been  driven  with  a  crash 
through  the  brain  of  a  man  who  is  still  able  to  walk  off, 
talking  with  composure  and  equanimity  of  the  hole  in  his 
head.  This  is  the  sort  of  accident  that  happens  in  the  pan- 
tomime at  the  theatre,  but  not  elsewhere.  Yet  there  is  every 
reason  for  supposing  it  in  this  case  literally  true.  Being  at 
first  wholly  sceptical,  I  have  been  personally  convinced ;  and 
this  has  been  the  experience  of  many  medical  gentlemen 
who,  having  first  heard  of  the  circumstances,  have  had  a 
subsequent  opportunity  to  examine  the  evidence. 

This  evidence  is  comprised  in  the  testimony  of  individuals, 
and  in  the  anatomical  and  physiological  character  of  the 
lesion  itself. 

The  above  accounts  from  different  individuals  concur  in 
assigning  to  the  accident  a  common  cause.  They  are 
selected  as  the  most  complete  among  about  a  dozen  of  sim- 
ilar documents  forwarded  to  me  by  Dr.  Harlow,  who  was 
kind  enough  to  procure  them  at  my  request.  They  bear  the 
signature  of  many  respectable  persons  in  and  about  the  town 
of  Cavendish,  and  are  all  corroborative  of  the  circumstances 
as  here  detailed.  The  accident  occurrec^  in  open  day,  in  a 
quarry  in  which  a  considerable  number  of  men  were  at  work, 


184  CASE   OF   INJURY   OF   HEAD. 

many  of  whom  were  witnesses  of  it,  and  all  of  whom  were 
attracted  by  it.  Suffice  it  to  say,  that  in  a  thickly  populated 
country  neighborhood,  where  all  the  facts  were  matter  of 
daily  discussion  at  the  time  of  their  occurrence,  there  is  no 
difference  of  belief,  nor  has  there  been  at  any  time  a  doubt 
that  the  iron  was  actually  driven  through  the  brain.  A 
considerable  number  of  medical  gentlemen  also  visited  the 
case  at  various  times  to  satisfy  their  incredulity. 

Assuming  that  the  wound  was  the  result  of  a  missile  pro- 
jected from  below  upwards,  it  may  be  asked  whether  the 
wound  might  not  have  been  made  by  a  stone,  while  the  bar 
was  at  the  same  moment  thrown  into  the  air.  It  may  be 
said  in  reply,  that  the  rock  was  not  split,  nor,  as  far  as 
could  be  learned,  disintegrated.  Besides,  an  angular  bit  of 
stone  would  have  been  likely  to  have  produced  quite  as  much 
laceration  as  the  bar  of  iron ;  and  it  is  in  fact  possible  that 
the  tapering  point  of  the  latter  divided  and  repelled  the  soft 
parts,  especially  the  brain,  in  a  way  that  enabled  the  smooth 
surface  of  the  iron  to  glide  through  with  less  injury.  As- 
suming the  only  possible  hypothesis,  that  the  round  bar 
followed  exactly  the  direction  of  its  axis,  the  missile  may 
be  considered  as  a  sphere  of  one  and  a  quarter  inches  in 
diameter,   preceded  by  a  conical  and  polished  wedge. 

The  patient  visited  Boston  in  January,  1850,  and  re- 
mained some  time  under  my  observation,  during  which  he 
was  presented  at  a  meeting  of  the  Boston  Society  for  Medical 
Improvement,  and  also  to  the  medical  class  at  the  Hospital. 
His  head,  now  perfectly  healed,  exhibits  the  following 
appearances. 

A  linear  cicatrix  of  an  inch  in  length  occupies  the  left 
ramus  of  the  jaw  near  its  angle.  A  little  thickening  of  the 
soft  tissues  is  discovered  about  the  corresponding  malar 
bone.  The  eyelid  of  this  side  is  shut,  and  the  patient  unable 
to  open  it.     The  left  eye,  considerably  more  prominent  than 


CASE   OF   INJURY   OF   HEAD.  185 

the  other,  offers  a  singular  confirmation  of  the  points  illus- 
trated by  the  prepared  skull  described  below,  where  it  will  be 
seen  that  the  parts  of  the  orbit  necessarily  cut  away  are  those 
occupied  by  the  levator  palpebrge  superioris,  the  levator  oculi, 
and  the  abducens  muscles.  In  addition  to  a  ptosis  of  the  lid, 
the  eye  is  found  to  be  incapable  of  executing  either  the  out- 
ward or  upward  motion ;  while  the  other  muscles  animated 
by  the  motor  communis  are  unimpaired.  Upon  the  head, 
and  covered  by  hair,  is  a  large  unequal  depression  and 
elevation.  A  portrait  of  the  cast  of  the  shaved  head  is 
given  in  the  plate ;  and  it  will  be  seen  that  a  piece  of  cranium 
of  about  the  size  of  the  palm  of  the  hand,  its  posterior  border 
lying  near  the  coronal  suture,  its  anterior  edge  low  upon  the 
forehead,  was  raised  upon  the  latter  as  a  hinge  to  allow  the 
egress  of  the  bar;  and  that  it  still  remains  raised  and  prom- 
inent. Behind  it  is  an  irregular  and  deep  sulcus  several 
inches  in  length,  beneath  which  the  pulsations  of  the  brain 
can  be  perceived. 

In  order  to  ascertain  how  far  it  might  be  possible  for  this 
bar  of  an  inch  and  a  quarter  diameter  to  traverse  the  skull 
in  the  track  assigned  to  it,  I  procured  a  common  skull  in 
which  the  zygomatic  arches  are  barely  visible  from  above, 
and,  having  entered  a  drill  near  the  left  angle  of  the  lower 
jaw,  passed  it  obliquely  upwards  to  the  median  line  of  the 
cranium  just  in  front  of  the  junction  of  the  sagittal  and 
coronal  sutures.  This  aperture  was  then  enlarged  until  it 
allowed  the  passage  of  the  bar  in  question,  and  the  loss  of 
substance  strikingly  corresponds  with  the  lesion  received  by 
the  patient.  From  the  coronoid  process  of  the  lower  jaw  a 
fragment  measuring  about  three  quarters  of  an  inch  in  length 
■was  removed.  This  fragment  in  the  patient's  case  might 
have  been  fractured,  and  subsequently  reunited. 

The  track  of  the  opening  now  passes  obliquely  beneath 
the  zygomatic  arch,  encroaching  equally  upon  all  its  walls. 


186  CASE   OF   INJURY   OF   HEAD. 

In  fact,  it  entirely  occupies  this  space;  the  posterior  wall 
of  the  antrum  being  partially  excavated  at  the  front,  the 
whole  orbitar  portion  of  the  sphenoid  bone  being  removed 
behind,  as  also  the  anterior  part  of  the  squamous  portion  of 
the  temporal  bone,  and  the  internal  surface  of  the  zygoma 
and  malar  bone  laterally.  In  the  orbit,  the  sphenoid  bone, 
part  of  the  superior  maxillary  below,  and  a  large  part  of  the 
frontal  above,  are  cut  away,  and  with  these  fragments  much 
of  the  spheno-maxillary  fissure,  leaving,  however,  the  optic 
foramen  intact  about  a  quarter  of  an  inch  to  the  inside  of  the 
track  of  the  bar. 

The  base  of  the  skull  upon  the  inside  of  the  cranium  pre- 
sents a  circular  hole  of  an  inch  and  a  quarter  in  diameter, 
and  such  as  may  be  described  by  a  pair  of  compasses  one 
leg  of  which  is  placed  upon  the  lesser  wing  of  the  sphenoid 
bone  at  an  eighth  of  an  inch  from  its  extremity,  the  other 
half  an  inch  outside  the  internal  optic  foramen,  cutting  the 
frontal,  temporal,  and  sphenoid  bones. 

The  calvaria  is  perforated  by  a  hole,  two  thirds  of  which 
is  upon  the  left  and  one  third  upon  the  right  of  the  median 
line,  its  posterior  border  being  quite  near  the  coronal  suture. 
The  iron  freely  traverses  the  oblique  track  thus  described. 

It  is  obvious  that  a  considerable  portion  of  the  brain  must 
have  been  carried  away ;  that  while  a  portion  of  its  lateral 
substance  may  have  remained  intact,  the  whole  central  part 
of  the  left  anterior  lobe  and  the  front  of  the  sphenoidal  or 
middle  lobe  must  have  been  lacerated  and  destroyed.  This 
loss  of  substance  would  also  lay  open  the  anterior  extremity 
of  the  left  lateral  ventricle;  and  the  iron  in  emerging  from 
above  must  have  largely  impinged  upon  the  right  cerebral 
lobe,  lacerating  the  falx  and  the  longitudinal  sinus.  Yet  the 
optic  nerve  remained  unbroken  in  the  narrow  interval  between 
the  iron  and  the  inner  wall  of  the  orbit.  The  eye,  forcibly 
thrust  forward  at  the  moment  of  the  passage,   might   have 


CASE   OF  INJURY  OF   HEAD.  187 

receded  into  its  socket,  from  which  it  was  again  somewhat 
protruded  during  the  subsequent  inflammation. 

It  is  fair  to  suppose  that  the  polished  conical  extremity  of 
the  iron,  which  first  entered  the  cavity  of  the  cranium,  pre- 
pared the  way  for  the  thick  cylindrical  bar  which  followed ; 
and  that  the  point  of  the  bar,  in  reaching  and  largely  break- 
ing open  the  vault  of  the  cranium,  afforded  an  ample  egress 
for  the  cerebral  substance,  thus  preventing  compression  of 
the  remainder. 

Yet  it  is  difficult  to  admit  that  a  passage  could  have  been 
thus  violently  forced  through  without  a  certain  comminution 
of  the  base  of  the  skull  driven  inwards  upon  the  cranial 
cavity. 

Little  need  be  said  of  the  physiological  possibility  of  this 
history.  It  is  well  known  that  a  considerable  portion  of  the 
brain  has  been  in  some  cases  abstracted  without  impairing  its 
functions.  Atrophy  of  an  entire  cerebral  hemisphere  has 
also  been  recorded. 

But  the  remarkable  features  of  the  present  case  lie  not  only 
in  the  loss  of  cerebral  substance,  but  also  in  the  singular 
chance  which  exempted  the  brain  from  either  concussion  or 
compression ;  which  guided  the  enormous  missile  exactly  in 
the  direction  of  its  axis,  and  which  averted  the  dangers  of 
subsequent  inflammation.  An  entire  lung  is  often  disabled 
by  disease ;  but  I  believe  there  is  no  parallel  to  the  case  in 
the  Hunterian  collection  of  a  lung  and  thorax  violently  trans- 
fixed by  the  shaft  of  a  carriage. 

Taking  all  the  circumstances  into  consideration,  it  maybe 
doubted  whether  the  present  is  not  the  most  remarkable  his- 
tory of  injury  to  the  brain  which  has  been  recorded.^ 

^  The  iron  bar  has  been  deposited  in  the  museum  of  the  Medical 
School  of  Harvard  University,  where  it  may  be  seen,  together  with  a  cast 
of  the  patient's  head. 


188  CASE  OF   INJURY  OF   HEAD. 


DESCRIPTION   OF  THE  PLATE. 

1.  Lateral  view  of  a  prepared  cranium,  representing  the  iron  bar  in 
the  act  of  traversing  its  cavity. 

2.  Front  view  of  the  same. 

3.  Plan  of  the  base  seen  from  within.  (In  these  three  figures  the  optic 
foramina  are  seen  to  be  intact,  and  occupied  by  small  white  rods.  Li  the 
first  two  figures,  no  attempt  has  been  made  to  represent  the  elevation 
of  the  large  anterior  fragment,  which  must  have  been  more  considerable 
than  is  here  shown.) 

4.  Cast  taken  from  the  shaved  head  of  the  patient,  and  representing 
the  present  appearance  of  the  fracture ;  the  anterior  fragment  being  con- 
siderably elevated  in  the  profile  view. 

5.  The  iron  bar  of  length  and  diameter  proportioned  to  the  size  of  the 
other  figures. 


STRICTURES  OF  THE  URETHRA.  189 


EMPLOYMENT  OF  A  NEW  AGENT  IN  THE  TREAT- 
MENT OF  STRICTURES  OF  THE  URETHRA,  i 

This  method  consists  essentially  in  the  use  of  gutta  percha 
in  taking  the  impression  of  a  stricture ;  and  also  avails  itself 
of  the  plasticity  of  this  gum  in  dilating  the  stricture. ^ 

There  is,  in  general,  no  great  difficulty  in  the  treatment 
of  a  stricture  near  the  orifice  of  the  urethra.  On  the  other 
hand,  a  contraction  of  the  canal  far  back  towards  the 
perineum  often  presents  serious  difficulties.  The  introduc- 
tion of  an  instrument  is  then  sometimes  impracticable,  or 
requires  a  tedious  and  very  careful  manipulation.  It  is 
plain  that  one  great  difficulty  exists  in  the  inability  on  the 
part  of  the  surgeon  to  ascertain  the  precise  character  of 
the  lesion,  —  the  geography  of  the  part  to  be  traversed  by 
the  bougie.  It  is  well  known  that  this  contraction  is  sus- 
ceptible of  infinite  variation.  It  is  abrupt  or  gradual,  con- 
centric or  lateral,  straight,  angular,  curved  or  spiral,  smooth 
or  knobbed,  long  or  short,  and  finally  partial  or  exaggerated ; 
and  against  all  these  varieties  the  principal  weapon  in  the 
hands  of  the  surgeon  is  the  bougie.  This  instrument,  with 
little  available  variety,  either  in  its  material  or  conforma- 
tion, has  a  point  attenuated  or  obtuse,  urged  by  a  force 
applied  at  perhaps  six  inches'  distance;  and  is  expected  to 
thread   its  way  along   the   complicated  and    winding   laby- 

1  Boston  Medical  and  Surgical  Journal,  February  7,  1849. 

2  The  use  of  gutta  percha  bougies  is  not  new ;  it  is  attributed  to  a 
physician  at  Singapore ;  but  I  have  neither  seen  nor  heard  any  allusion 
to  their  being  employed  to  take  impressions  of  strictures,  which,  so  far  as 
I  can  judge,  constitutes  their  chief  if  not  their  only  value. 


190  STRICTURES  OF  THE   URETHRA. 

rinth  which  often  constitutes  a  stricture.  Fortunately,  the 
healthy  canal  traversed  by  the  bougie  generally  so  directs  it 
that,  when  the  contraction  is  not  great,  the  point  enters  its 
orifice  after  more  or  less  manipulation.  Yet  it  will  be  con- 
ceded that  this  manipulation,  however  delicate  and  skilful, 
is  often,  and  of  necessity,  only  a  series  of  tentative  thrusts 
or  offers,  made  in  the  dark,  in  the  hope  of  ultimately  discov- 
ering and  traversing  some  interval  or  interstice  should  such 
exist. 

Other  circumstances,  such  as  the  density  and  character  of 
the  opposing  tissue,  and  the  necessity  of  employing  or  of 
avoiding  protracted  pressure,  complicate  the  problem. 

The  common  method,  it  is  true,  is  often  quite  effectual 
and  satisfactory;  especially  in  the  ordinary  run  of  cases  of 
simple  or  partial  contraction.  Yet  there  is  something  gross 
in  it.  It  is  wanting  in  the  nicer  modifications  of  art  which 
should  characterize  surgical  manipulation,  when  they  do  not 
interfere  with  its  simplicity.  Nor  are  the  results  of  this  pro- 
cess always  beneficial,  especially  when  the  case  is  difficult, 
or  the  operator  inexpert.  It  will  soon  be  shown  that  false 
passage  is  very  common  in  connection  with  old  stricture ; 
simply  because  the  propelled  instrument,  finding  no  natural 
canal,  has  made  one  for  itself.  Or,  as  not  unfrequently 
occurs,  when  the  urine  merely  dribbles  away,  no  canal  can 
be  detected  and  no  instrument  of  dilatation  passed. 

These  difficulties  are  not  new.  Different  methods  have 
been  devised  to  bring  the  part  to  be  operated  upon  more 
directly  in  contact  with  the  senses  of  the  operator;  such  as 
a  lamp  to  illuminate  the  stricture,  and  a  tube  by  which 
to  see  it.  Ducamp  insisted  upon  the  great  advantage  of 
impressions  in  wax,  as  conveying  an  idea  of  the  confor- 
mation of  a  stricture,  and  contrived  hollow  tubes,  contain- 
ing eccentric  bougies  sliding  out  like  a  telescope  at  one  side 
of  the  distorted  canal. 


STRICTURES   OF  THE   URETHRA.  191 

Whoever  has  tried  this  wax  has  probably  found  that, 
however  good  the  impression  received  in  the  interior  of  the 
passage  may  be,  it  is  lost  either  when  the  material  is  extri- 
cated from  the  stricture  or  subsequently  from  the  urethra. 
It  is  of  questionable  utility  in  this  point  of  view.  Besides, 
the  wax  is  soft  and  liable  to  break ;  and  lastly,  when  moulded 
to  the  shape  of  the  canal,  it  is  itself  of  no  use  in  dilating 
it,  and  another  instrument  of  corresponding  outline  must  be 
arranged  for  this  purpose. 

The  advantages  of  gutta  percha  are,  first,  that  it  is  prob- 
ably the  only  material  in  the  world  capable  of  receiving  a 
sharp  impression  at  a  temperature  quite  comfortable  to  the 
skin,  and  at  the  same  time  of  retaining  it  entirely  at  about 
the  actual  temperature  of  the  body,  afterward  becoming  hard 
and  resisting,  and  exceedingly  tough,  even  in  attenuated 
filaments.  It  follows  that,  upon  being  withdrawn  from  the 
urethra,  it  presents  a  perfect  impression  of  the  most  minute 
inequalities  of  the  callous  tissue  against  which  it  has 
impinged. 

In  the  second  place,  it  may  be  used  when  thus  moulded  as 
a  dilator  of  the  stricture ;  and  it  can  be  made  to  enter  with 
unerring  certainty  any  of  its  orifices. 

A  few  words  will  suffice  to  describe  the  method  I  have 
adopted  in  employing  these  bougies.  A  medium  size  answers 
a  good  purpose,  unless  there  be  strictures  anterior  to  the  one 
to  be  treated,  in  which  case  a  small  calibre  is  sometimes 
requisite.  Let  the  bougie  be  oiled  and  the  tip  passed  to  and 
fro  rapidly  in  the  edge  of  the  flame  of  a  candle  until  it  is  so 
warm  that  the  nail  will  indent  it;  the  mass  will  remain 
plastic  after  the  surface  has  ceased  to  be  hot,  and,  being 
very  smooth  and  pliable,  may  be  rapidly  passed  down  to  the 
stricture.  If  it  be  pressed  against  the  stricture  for  a  minute 
with  a  force  equivalent  to  an  ounce  or  two  of  weight,  and 
then  left  to  cool  during  the  succeeding  three  or  four  minutes. 


192  STRICTURES  OF  THE  URETHRA. 

it  will  present,  when  slowly  and  carefully  disengaged  from 
the  stricture,  a  firm  and  unyielding  impression  of  the  most 
minute  inequality  and  indentations  of  the  callous  surface. 
The  tip  may  be  cut  off  and  preserved,  furnishing,  with 
others,  a  complete  history  of  the  conformation  of  the  stric- 
ture under  treatment. 

If  water  be  employed  to  heat  the  gum,  it  will  be  found  that 
the  steam  from  the  surface  will  soften  the  rod  for  the  length 
of  an  inch  or  more;  rendering  it  liable  to  curl  up  against 
the  stricture,  as  small  elastic  bougies  are  apt  to  do.  The 
tip  alone  should  be  softened.  On  the  other  hand,  care  should 
be  taken  not  to  burn  the  gum ;  as  its  texture  and  ability  to 
harden  are  thus  destroyed,  and  a  piece  may  be  left  in  the 
stricture.  Such  a  case  occurred  to  me.  A  plug,  in  one  case, 
was  thus  left  in  a  small  stricture,  causing  retention  during 
eighteen  hours ;  w^hen,  the  orifice  having  become  dilated, 
the  plug  was  forced  out  by  the  urine,  which  then  flowed 
more  freely  than  for  many  months  before. 

Pure  gutta  percha  softens  most  readily,  and  cools  with 
least  elacticity  and  shrinking.  It  is  therefore  far  better  for 
impressions  than  when  adulterated,  as  is  common  with  caout- 
chouc. But  when  pure,  a  little  oiling  and  use  soon  raise  a 
fur  upon  its  surface ;  so  that  it  is  probable  that  some  com- 
pound will  answer  better  for  mere  bougies. 

I  have  hitherto  made  these  bougies  from  pure  gum,  of  the 
thickness  of  sole  leather,  cut  into  square  strips,  plunged  into 
boiling  water,  and  rolled  between  two  boards,  care  being 
taken  to  prevent  twisting. 

When  the  bougie  is  embedded  in  the  stricture,  let  its 
head,  or  external  end,  be  warmed  and  flattened  in  a  vertical 
or  transverse  direction  with  reference  to  the  pubes,  and  it 
will  indicate,  when  withdrawn,  the  position  of  the  inequal- 
ities in  regard  to  the  periphery  of  the  canal. 

Suppose,   now,  that  the  impression,   as  is  frequently  the 


STRICTURES  OF  THE   URETHRA.  193 

case,  is  forked.  Examination  of  the  extremities  often  indi- 
cates which  is  the  true  passage  and  which  the  false;  or  if 
not,  the  larger  is  generally  the  true  passage.  Let  the  false 
extremity  be  carefully  shaved  off  and  the  bougie  returned 
into  the  urethra,  its  flattened  head  maintaining  its  relative 
position  to  the  pubes.  It  forms  a  conical  bougie  of  the  best 
description,  exactly  adapted  to  the  form  of  the  true  passage, 
which  it  inevitably  enters.  Impressions  also  record  and 
especially  direct  the  progress  of  a  cutting  instrument,  as 
seen  in  the  accompanying  sketches. 

The  general  pathology  of  stricture  is  not  here  discussed; 
but  it  will  be  quite  obvious  that  there  are  cases  of  irritable 
and  inflammatory  stricture  in  which  this  method  of  dilata- 
tion, as  well  as  all  other  active  mechanical  treatment,  would 
be  inappropriate.  Nor  are  the  relative  merits  of  dilata- 
tion, incision,  and  cauterization  considered.  Each  is  occa- 
sionally a  valuable  resource;  the  success  of  all  is  incalcu- 
lably aided  by  the  knowledge  derived  from  impressions; 
while  the  first,  by  far  the  most  valuable  mode  of  treatment, 
is  considerably  accelerated  by  the  actual  employment  of  the 
gutta  percha. 

A  few  sketches  will  give  an  idea  of  the  character  of  the 
impressions.  They  are  selected  from  a  considerable  number, 
to  illustrate  several  points. 

The  first  line  of  the  annexed  print  presents  impressions 
with  false  passages,  taken  in  the  course  of  the  treatment  of 
the  first  case  detailed  below.  The  first  three  figures  repre- 
sent different  impressions  taken  early  in  the  treatment.  The 
fourth  and  fifth  represent  the  bougies  used  as  dilators  after 
the  impression  of  the  false  passage  was  removed;  and  the 
last  figure  shows  the  impression  when  the  canal  was  easily 
pervious  to  a  moderate-sized  bougie. 

The  figures  numbered  2  are  different  impressions  of  an- 
other stricture  at  different  periods  of  treatment.    Number  8 

13 


194  STRICTURES  OF  THE   URETHRA. 

is  an  old  stricture,  nearly  impervious,  from  a  patient  who 
died  of  inflammation  of  the  membranous  portion  of  the  ure- 
thra. Numbers  4  and  5  are  impressions  of  incisions.  These 
incisions  were  made  with  Ratier's  instrument,  sketched 
below  in  this  connection,  and  which  is  by  far  the  best  of  a 
number  I  have  employed.  The  blade  slides  back  obliquely 
into  the  canula.  Number  6  is  an  excellent  impression  of  an 
old  stricture.  Two  perfectly  similar  impressions  were  taken 
upon  succeeding  days,  indicatinc^  that  no  doubt  could  exist 
of  the  character  of  its  outline.  The  stricture  was  incised 
exactly  at  the  point  calculated,  the  parallel  lines  indicating 
where  the  impression  of  the  two  incisions  seen  in  the  small 
figure  corresponds  with  the  original  impression.  Number  8 
represents  the  last  impression  of  these  and  subsequent  incis- 
ions, three  days  after  which  the  canal  was  entirely  pervious. 
These  are  from  the  second  case  detailed  below.  Numbers 
7  and  9  are  given  as  good  impressions  of  curious  stric- 
tures. 

The  following  are  two  cases  of  bad  strictures,  which  had 
resisted  previous  treatment.  I  believe  the  success  attending 
their  ultimate  treatment  to  be  due  to  the  assistance  derived 
from  the  gutta  percha.  They  are  here  detailed  as  the  first 
cases  subjected  to  this  treatment,  and  they  were  examined 
by  various  professional  gentlemen  from  different  parts  of 
the  country  who  happened  to  visit  the  Hospital  during  the 
summer  of  1848,  and  an  account  of  them  was  read  to  the 
Boston  Society  for  Medical  Improvement  soon  after  their 
occurrence. 

Obstinate  Traumatic  Stricture^  with  Fistula  behind  Scrotum. 
,  aet.  38.     Patient  has  had  gonorrhoea  many  times, 


—  the  last  time  four  years  ago.  In  1832,  after  exposure  to 
cold  and  wet,  great  difficulty  in  micturition.  Again,  in 
1837,   a  similar  attack. 


STRICTURES  OF  THE   URETHRA.  195 

June  1,  1848.  —  Eighteen  months  ago  fell  astride  of  the 
rail  of  a  ship;  was  made  insensible,  and  afterwards  had 
much  difficulty  in  urinating,  and  passed  bloody  urine.  Last 
July,  after  micturition,  a  swelling  formed  in  perineum,  just 
behind  scrotum,  which  opened  externally,  and  through  the 
opening  pus  and  urine  escaped  together.  Urine  has  flowed 
more  or  less  in  this  way  since. 

Now,  penis  and  scrotum  swollen ;  the  scrotum  quite  dense, 
firm,  enlarged  and  thickened,  especially  at  posterior  part. 

Just  behind  the  scrotum  is  a  small  red  eminence  which 
marks  the  entrance  of  a  fistula,  from  which  urine  drops  at 
every  micturition. 

The  smallest  sized  catheter  passes  through  a  stricture  just 
in  front  of  the  scrotum,  but  is  arrested  about  two  and  a  half 
inches  farther  on  by  a  stricture  into  which  it  passes  about  half 
an  inch. 

Has  had  much  fruitless  treatment  with  instruments  before 
entering  the  Hospital,  and  is  sure  none  have  ever  entered 
bladder  until  about  a  month  ago,  when  a  small  steel  wire 
was  passed  twice  or  three  times  by  the  patient  himself,  which 
was  followed  by  much  constitutional  irritation. 

Patient  states  that  he  is  unable  now  to  discover  this  canal, 
to  which  chance  directed  the  instrument.  In  the  course  of 
several  explorations,  I  succeeded  in  passing  the  wire  once ; 
but  the  mass  was  dense  and  cartilaginous  to  the  touch,  and  it 
was  evident  that  nothing  could  be  gained  except  by  consecu- 
tive dilatation,  which  it  was  impossible  to  adopt,  on  account 
of  the  uncertainty  of  entering  the  stricture  without  pro- 
tracted and  irritating  manipulation.  This  was  a  stricture  of 
the  worst  class,  a  long  and  dense  cicatrix,  complicated  both 
with  a  false  passage  at  its  entrance  which  was  liable  to 
engage  the  bougie,  and  with  an  old  fistulous  sinus. 

June  3.  —  An  impression  of  the  stricture  was  taken  with 
engravers'  wax ;  but  this  being  unsatisfactory  in  its  indica- 


196  STRICTURES  OF  THE  URETHRA. 

tions,  the  gutta  percha  was  tried  the  next  day,  and  yielded, 
from  the  orifice  of  the  stricture,  one  of  the  first  three  impres- 
sions of  which  a  sketch  is  given  in  the  plate.  In  the  course 
of  the  week,  as  the  patient  was  able  to  bear  the  treatment, 
the  false  spur  was  removed  from  the  bougie,  as  shown  in  the 
sketch,  and  the  rod,  guided  by  the  flattened  head,  was  passed 
into  the  true  canal. 

On  the  16th,  by  the  same  guide,  incisions  were  made  with 
Ratier's  instrument ;  and  on  the  23d,  three  weeks  from  the 
beginning  of  treatment,  a  small  silver  catheter  was  easily 
passed  into  the  bladder  and  left  there. 

July  6,  the  patient  was  able  to  retain  a  medium-sized 
flexible  bougie  for  an  hour  or  two  without  pain. 

July  15.  — "  Now  introduces,  and  wears  with  ease,  a 
No.  11  flexible  catheter."  The  last  impression  is  shown  in 
the  plate. 

At  this  time  he  suffered  from  a  severe  constitutional 
attack.  Pain  in  the  scrotum,  with  swelling,  general  heat, 
pulse  100,  tongue  furred.  On  the  second  day,  anorexia  and 
nausea,  pulse  116.  Not  relieved  by  an  emetic.  On  the 
third  day,  pulse  160,  much  nausea.  Being  unable  to  dis- 
cover other  local  difficulty,  after  careful  exploration  of  the 
viscera  and  functions,  and  the  patient  looking  badly,  I 
determined  to  divide  the  scrotum  on  its  posterior  aspect, 
which  was  done.  The  patient  being  etherized  and  placed 
as  for  lithotomy,  and  with  the  valuable  assistance  of  Dr. 
Townsend,  a  grooved  staff  was  passed  into  the  bladder,  and 
an  incision  about  three  and  a  half  or  four  inches  long  was 
made  in  the  perineum,  through  the  thickened  callus,  until, 
at  the  depth  of  nearly  three  inches,  the  sound  was  exposed  and 
the  urethra  divided  to  some  extent,  and  nearly  as  far  as  the 
bladder,  for  the  purpose  of  including,  if  possible,  the  inter- 
nal orifice  of  the  old  fistula.  The  source  of  the  constitu- 
tional trouble  appeared  in  a  small  collection  of  pus  in  the 


STRICTURES  OF  THE  URETHRA.  197 

centre  of  the  callus  and  quite  near  the  urethra.  During 
the  three  succeeding  days  the  pulse  was  successively  128, 
120,  90,  with  returning  appetite  and  corresponding  improve- 
ment in  appearance. 

From  this  time  the  patient  steadily  improved.  Ointments, 
fomentations  and  poultices,  compression  and  bandages,  were 
applied  as  indicated,  the  patient  soon  taking  into  his  own 
hands  the  treatment  by  bougies,  of  which  he  wore  or  passed 
with  ease  the  larger  sizes,  until  in  November  the  urine  flowed 
in  a  good  stream,  with  a  drop  or  two  from  the  perineum  once 
in  two  or  three  days.  The  patient  left  the  Hospital  at  the 
end  of  the  year,  with  a  bougie  to  gage  occasionally  the  cali- 
bre of  his  urethra,  and  much  gratified  with  his  improved 
condition. 

Stricture  of  the  Cavernous  Portion^  with  Fistula. , 


set.  72.  "Reports  that  after  exposure  to  cold  eleven  years 
ago  stricture  was  first  troublesome,  A  year  ago,  after  another 
severe  exposure,  stricture  again  annoyed  him,  and  he  was 
treated  with  bougies.  Five  months  ago  suffered  from  reten- 
tion of  urine,  and  at  this  time  a  fistula  formed  behind  the 
stricture,  through  which  most  of  the  urine  has  since  escaped. " 

September  20,  1848.  —  "A  fistula  exists  at  the  right  side 
of  the  scrotum,  of  considerable  size.  Urine  passes  chiefly 
through  this  passage." 

September  21.  —  "A  gutta  percha  bougie  was  passed,  which 
retained,  on  being  withdrawn,  the  perfect  form  of  the  stric- 
ture. " 

This  impression,  numbered  6  in  the  plate,  was  twice  taken 
at  the  interval  of  two  days,  leaving  no  doubt  of  its  accuracy. 
It  exhibits  a  minute  prolongation  like  the  head  of  a  snake, 
and  indicates  an  almost  complete  obliteration  of  the  canal. 

From  this  period  till  the  end  of  the  month  the  stricture 
was   several   times   incised,   and    a  number   of   impressions 


198  STRICTURES  OF  THE   URETHRA. 

taken,  the  first  of  which,  with  two  incisions,  is  represented 
at  No.  6  bis,  while  the  last  is  given  at  No.  8,  showing  how 
large  a  calibre  the  canal  had  then  attained.  The  stream  of 
urine  was  now  tolerably  free,  while  the  dribbling  of  the 
fistula  had  decreased,  but,  the  canal  being  somewhat  sore  at 
the  incised  portion,  I  forbore  to  pass  an  instrument  into  the 
bladder.  A  few  days  afterward,  my  friend  Dr.  Warren,  Jr., 
who  at  this  time  succeeded  me  in  the  charge  of  the  ward, 
informed  me  that  an  instrument  had  readily  passed  the 
former  strictures  into  the  bladder. 

In  the  course  of  three  weeks  the  patient  left  the  hospital 
with  a  canal  of  good  diameter,  and  provided  with  a  flexible 
bougie  for  his  own  use.  The  fistula  was  not  entirely  healed, 
yet  no  urine  passed  by  it. 

It  is  well  known  that  old  fistulse  in  the  urethra  rarely  heal, 
but  they  are  comparatively  harmless.  On  the  other  hand,  the 
stricture  which  accompanies  and  produces  them  is  capable 
of  causing  infinite  mischief.  An  instance  of  this  occurred 
to  me  while  the  above  cases  were  under  treatment. 

A  patient  about  forty-five  years  of  age,  had  a  stricture  of  a 
number  of  years  standing.  Exposure  aggravated  it,  and 
caused  retention.  The  urethra  burst  behind  the  scrotum, 
and  when  I  saw  him,  on  the  fifth  day,  the  penis  and  scrotum 
were  tumefied  and  gangrenous.  A  little  oedema  only  existed 
about  and  above  Poupart's  ligament;  yet  I  deemed  it  ad- 
visable to  incise,  not  only  the  former  regions,  but  also  the 
integuments  of  the  abdomen  on  both  sides.  Much  urine 
escaped  from  the  scrotum  and  cellular  tissue  of  the  penis, 
while  that  of  the  abdomen  appeared  healthy  throughout  the 
course  of  an  oblique  incision  in  each  iliac  region  three  or 
four  inches  in  length,  and  as  deep  as  the  tendon  of  the  ex- 
ternal oblique.  A  few  days  sufficed  to  show  that  here  also 
the   cellular   membrane   beneath   the  superficial  fascia  was 


STRICTURES   OF  THE   URETHRA.  199 

infiltrated  with  urine,  for  an  apron  of  slough  was  soon 
formed  between  skin  and  muscle,  as  high  as  the  navel  and 
laterally  backward,  discharging  pus  with  urine  profusely, 
and  the  patient  succumbed  on  the  seventeenth  day. 

All  of  these  were  cases  of  obstinate  stricture  of  long 
duration.  Two  had  undergone  protracted  treatment  with- 
out success,  one  of  them  in  two  hospitals ;  and,  inasmuch  as 
patients  with  old  strictures  usually  get  to  be  in  some  meas- 
ure connoisseurs  of  local  treatment,  their  voluntary  attesta- 
tions may  be  considered  as  having  some  weight  in  favor  of 
the  facility  and  efficacy  of  the  treatment  by  gutta  percha. 


200  NOTES  FROM  CLINICAL  LECTURES. 


NOTES  FROM  CLINICAL  LECTURES  ON  SURGERY. i 

November  11,  1850. —  The  present  hour  is  allotted  to  the 
purposes  of  clinical  instruction ,  to  the  consideration  of  cases 
of  surgical  disease  in  the  details  of  their  history,  immediate 
antecedents,  symptoms,  and  treatment.  This  is  a  mode  of 
study  which  has  been  before  spoken  of,  and  is  opposed  to 
that  abstract  and  general  account  of  disease  which  is  adopted 
by  treatises.  It  is,  indeed,  the  natural  method  of  study; 
the  order  in  which  experience  presents  itself  to  the  surgeon, 
and  in  which  it  should  be  made  to  present  itself  to  every  stu- 
dent of  our  science.  There  is  no  substitute  for  it.  Yet  we 
find  that  when  two  similar  cases  have  offered  themselves  to 
previous  observers,  it  has  happened  that  something  common 
to  both  has  been  drawn  from  them,  and  that  a  generalization 
has  thus  been  made ;  and  it  would  be  obvious  folly  not  to 
avail  ourselves  of  the  knowledge  and  teachings  of  those  who 
have  thus  previously  observed.  Clinical  study,  therefore, 
proposes  to  itself,  not  only  the  examination  of  a  detailed 
and  isolated  case,  but  also  contemplates  its  relations  with 
other  similar  cases.  It  investigates  the  eccentric  biography 
of  some  particular  instance  of  disease,  with  constant  refer- 
ence to  the  usual  and  common  history  of  the  same  disease, 
gaging  by  this  standard  the  irregularities,  and  endeavoring 
to  reconcile  to  this  standard  the  anomalies,  of  each  recurring 
case.  Our  clinical  study  will  be  confined  to  the  cases  we 
have  observed  together   during  visits  at  the  Massachusetts 

1  Boston  Medical  and  Surgical  Journal,  November  20,  27,  and  Decem- 
ber 4,  11,  25,  1850 ;  January  29  and  February  5,  1851. 


NOTES  FROM  CLINICAL  LECTURES.  201 

General  Hospital;  an  institution  which  has  no  superior,  and 
which  offers  great  facilities  for  the  observation  of  surgical 
disease.  It  will  be  found,  at  the  end  of  our  term,  that  a 
very  large  proportion  of  the  usual  surgical  affections  have 
passed  under  our  notice,  and  in  the  common  relative  fre- 
quency of  their  occurrence  in  the  routine  of  daily  practice. 
And  let  not  the  graver  and  striking  cases  claim  too  large  a 
share  of  your  attention ;  these  are  not  the  cases  which  you 
will  meet  with  in  your  daily  professional  walks.  But  it  is 
the  minor  and  seemingly  slight  and  trivial,  — the  chronic 
unchanging  and  unattractive  lesions,  which  will  fill  the 
sphere  of  your  daily  avocations,  and  upon  the  management 
of  which  will  depend  your  comfort  and  success.  In  addition 
to  the  surgical  cases  occurring  at  the  Hospital,  it  will  be  my 
duty  to  notice  the  surgical  operations  there  performed  before 
the  class ;  and  this  naturally  leads  to  the  consideration  of 
the  ansesthetics  so  constantly  administered. 

It  is  a  little  striking  that  those  who  are  in  the  daily 
habit  of  administering  anaesthetics  for  the  slight  operations 
of  dentistry,  or  in  midwifery,  are  often  startled  at  the  violent 
or  seemingly  dangerous  symptoms  which  sometimes  result 
from  the  administration  of  the  dose  required  for  protracted 
operations;  but  I  believe  that  any  one  who  shall  have  wit- 
nessed these  effects  during  a  brief  period  at  the  hospital, 
and  who  shall  have  learned  their  true  relation  to  the  anaes- 
thetic state,  especially  in  point  of  danger,  will  feel  himself 
at  home  in  administering  the  ether  in  any  emergency  what- 
ever. I  use  common  ether  (sulphuric).  Chloroform  has 
killed  people.  There  is  sufficient  evidence  that  patients  in 
good  health,  to  whom  chloroform  was  administered  in  the 
ordinary  way  and  with  ordinary  care,  have  become  pulseless, 
dead,  —  suddenly  and  without  warning.  Such  accident  has 
either  never  happened  with  ether,  or  is  excessively  rare. 
Chloric  ether  —  dilute  chloroform  —  blisters  the  skin,  which 


202  NOTES  FROM  CLINICAL  LECTURES. 

requires  abundant  oil  to  protect  it.  So  that,  on  the  whole, 
common  ether  is  safest,  cleanest,  simplest,  and  is  indeed, 
apart  from  its  odor,  a  perfect  anesthetic. 

Case  I.  Exstrophy  of  the  Bladder,  etc.  — This  unfortunate 
patient,  although  not  from  the  Hospital,  is  accustomed  to  offer 
himself  for  examination  here  and  elsewhere.  I  have  seen 
but  one  other  similar  case.  The  first  feature  which  strikes 
us  is  the  red,  raw,  and  inflamed  mucous  surface  of  the  pos- 
terior wall  of  the  bladder,  which  is  protruded  through  an 
orifice  in  its  anterior  wall  as  large  as  a  moderate-sized  apple, 
and  thence  through  the  abdominal  parietes.  It  is  thus  lit- 
erally turned  inside  out,  and  exhibits  the  ureters  dripping 
urine,  and,  below,  two  orifices,  which  the  patient  states  to 
be,  and  I  dare  say  are,  the  termination  of  the  spermatic 
ducts.  To  complete  this  median  division  of  the  tissues, 
there  is  entire  epispadias  of  the  penis  and  of  the  gland ; 
and  the  bones  of  the  symphysis  pubes  gape  to  the  extent  of 
many  inches.  You  will  observe,  besides,  an  inguinal  hernia, 
produced  very  likely  by  a  laxity  of  tendinous  fibres  which 
have  no  firm  insertion. 

This  is  an  instance  of  the  failure  on  the  part  of  nature  to 
unite  the  lateral  masses  of  the  body  upon  the  median  line, 
and  bears  analogy  to  certain  other  deformities,  such  as 
hypospadias,  hare  lip,  and  spina  bifida.     It  is  incurable. 

Case  II.  Epithelial  Disease  of  Lip.  —  Commonly  called 
cancer  of  the  lip,  and  with  good  reason ;  for  although  the 
affection  is  by  no  means  identical  with  cancer,  yet  it  has 
practically  many  of  its  destructive  properties.  It  affects  the 
skin  and  subjacent  cellular  tissue,  the  mucous  membrane, 
and  the  muscle.  The  man  operated  upon  on  Saturday  was 
about  fifty-two  years  of  age,  healthy,  and  of  a  fleshy  make. 
Two  years  ago  he  discovered  a  pimple  of  the  size  of  a  small 


NOTES   FROM   CLINICAL    LECTURES.  203 

pea  on  one  side  of  the  free  edge  of  the  under  lip.  A  year 
ago  this  had  attained  a  double  size,  and  was  covered  on  the 
buccal  margin  with  a  scab  of  ordinary  appearance  and  of  the 
size  of  a  half-dime.  This  patient  had  been  treated  by  some 
cancer  doctor,  as  such  lesions  often  are,  with  caustic,  but 
ineffectually.  I  removed  the  mass  by  a  V-shaped  incision  in 
the  sound  tissue,  and  the  edges  were  approximated  by  three 
or  four  sutures.  The  great  object  here  is  completely  to 
excise  the  disease ;  and  if  this  is  done,  it  has  little  tendency 
to  return,  differing  in  that  respect  from  true  cancer.  Now 
the  latter  disease  may  affect  the  lip  as  well  as  other  regions, 
and  hence  the  importance  of  establishing  distinctly  the  differ- 
ence between  the  two  diseases,  that  you  may  be  able  with 
confidence  to  assure  your  patient  of  his  probable  future.  And 
first  let  us  eliminate  the  advanced  stages  of  this  disease, 
where  the  bone  is  eroded  and  the  glands  are  affected.  In  such 
cases  extensive  plastic  operations  are  sometimes  necessary. 
I  have  removed  the  entire  lower  lip,  dissecting  the  cheeks 
back  to  the  facial  artery  of  each  side,  and  uniting  them 
when  drawn  forward  upon  the  median  line.  In  this  in- 
stance the  disease  returned  in  the  cicatrix  a  year  afterward. 
Extensive  ulceration  and  fungoid  growth  may  alter  the  gen- 
eral appearance  of  the  texture  to  a  degree  which  renders  its 
appearance  equivocal  without  the  aid  of  the  microscope. 
But  in  its  early  stage  the  epithelial  disease  of  the  lip  gen- 
erally shows  upon  section  a  dense  white  opaque  color,  and 
often  upon  minute  examination,  as  here,  vertical  strise  divid- 
ing it  into  apparent  columns,  which  either  terminate  at  the 
free  labial  edge,  disintegrating  into  a  paste  which  furnishes 
a  scab,  or  rise  above  it  to  a  considerable  height.  But  the 
microscope  leaves  no  doubt  in  the  majority  of  cases,  I  will 
not  say  all  cases ;  for  though  some  observers  have  no  question 
upon  this  point,  I  have  not  satisfied  myself  about  it.  In  most 
specimens  the  field  of  the  microscope,  as  in  the  present  in- 


204  NOTES   FROM   CLINICAL  LECTURES. 

stance,  exhibits  unequivocal  epithelial  features.  The  white 
caseous  mass  shows  the  normal  epithelial  cells  and  scales, 
every  irregularity  of  the  latter  varying  in  size  and  shape, 
while  the  distorted  cells  often  attain,  with  and  without  nuclei, 
enormous  size.  A  careful  observation  also  detects  little  groups 
of  the  minute  cells  in  the  first  period  of  their  growth. 

Such  is  the  common  disease  "cancer  of  the  lip,"  beginning 
with  a  small  purple  crust  or  scab,  and,  if  not  removed  in 
season,  attaining  an  ulcerated  growth  which  compromises 
the  life  of  the  individual ;  perfectly  curable  at  first,  but,  if 
neglected  or  tampered  with,  getting  beyond  the  reach  of  sur- 
gical art. 

Case  III.  Hare  Lip.  —  This  boy,  eight  or  nine  years  old, 
presenting  the  ordinary  appearances  of  a  bad  single  hare  lip, 
was  a  patient  of  my  friend  Dr.  Hayward.  The  fissure  reached 
the  left  nostril,  dividing  also  the  hard  and  soft  palate  in  the 
mouth.  You  observed  that  the  division  of  the  lip  was  a  little 
to  one  side  of  the  median  line.  It  is  always  so,  with  very 
rare,  if  any,  exceptions.  The  front  teeth  also  often  project, 
as  here,  where  one  had  been  recently  removed.  The  edges 
were  refreshed  and  brought  together  by  sutures.  We  rarely 
use  pins,  though  they  were  once  thought  essential.  Sutures 
answer  equally  well,  and  are  more  convenient.  The  upper 
one  should  be  carried  well  up  into  the  nostril  to  prevent 
a  gaping  and  ugly  orifice  at  that  point.  It  may  be  added, 
in  respect  of  these  sutures,  however  unscientific  the  avowal 
may  be  considered,  that  with  a  healthy  patient  and  good 
atmosphere,  sewing  skin  is  much  more  like  sewing  cloth 
than  is  generally  supposed.  It  is  better  to  add  stitches 
enough  to  adjust  the  parts  exactly  where  nicety  is  required, 
than  to  omit  them  and  trust  this  to  nature.  In  the  latter 
case,  the  gaping  interstice  gets  filled  with  lymph,  leaving 
a  broad  cicatrix,  or  an  edge  projects ;  so  that  altogether  we 


NOTES  FROM  CLINICAL  LECTURES.  205 

are  less  sure  of  the  result  than  when  the  edges  are  everywhere 
nicely  adjusted  aud  brought  together  as  has  been  described. 
I  never  saw  an  operation  for  hare  lip  which  did  not  leave  a 
slight  notch  or  fold  at  the  edge  of  the  lip.  In  fact,  the 
longitudinal  contraction  of  the  cicatrix  would  produce  this, 
but  you  may  avoid  it  almost  entirely  by  paring  the  free  edge 
well  down  to  the  orifice  of  the  mouth ;  let  the  cut  surfaces  be 
concave  rather  than  convex  towards  each  other;  and  dissect 
up  the  flaps  from  the  jaw  enough,  especially  in  infants,  to 
abate  the  lateral  traction.  Finally,  remove  the  stitches  with 
the  first  trace  of  suppuration  in  their  track,  or  you  will  have 
scars  to  mark  their  position.  This  operation  of  Dr.  Hay- 
ward's  will  probably  make  an  excellent  lip.  In  regard  to 
the  cleft  palate  of  this  boy,  where  it  is  so  wide,  it  is  unfavor- 
able for  operation.  I  have  produced,  contrary  to  my  expec- 
tation, a  good  union  of  the  posterior  portion,  in  a  similar 
case,  but  the  palate  was  afterwards  hard  and  tense  from  the 
contraction  which  ensued  upon  the  large  lateral  dissection 
necessary  to  loosen  the  scanty  flaps.  The  cicatrix  was  very 
different  from  the  pliant  and  serviceable  palate  which  we 
often  have  after  operation  where  the  cleft  is  not  so  wide. 

Case  TV.  Removal  of  Cicatrix  of  Neck  after  Burn.  — 
Some  of  you  have  before  seen  this  enormous  cicatrix  of  the 
neck  and  breast.  The  patient  was  burned  by  the  ignition  of 
matches  in  his  vest  pocket.  Last  year  I  divided  a  bridle  of 
the  neck,  and  with  real  relief  to  the  man.  Why  it  did  not 
again  contract,  it  is  difficult  to  say ;  but  the  fact  is,  that  he 
could  raise  his  chin  considerably  better  for  the  operation. 
The  whole  matter  of  the  contraction  of  cicatrices  is  uncer- 
tain. Some  diminish  almost  to  obliteration.  Others  remain 
loose  and  pliable  without  contraction.  Lymph  has  doubtless 
much  to  do  with  it;  but  we  generally  cannot  assign  the  direc- 
tion of  contraction.     Some  parts  of  this  scar  were  exquisitely 


206  NOTES  FROM  CLINICAL  LECTURES. 

and  finely  plicated  ;  while  other  parts  presented  large  welts, 
much  like  cheluides.  One  of  these,  about  the  size  of  a  finger 
and  the  seat  of  troublesome  suppuration,  I  removed  on  Satur- 
day from  the  lateral  hyoidal  region.  Such  masses  of  cicatrix 
are  usually  of  feeble  vitality,  but  this  Avas  nourished  by 
eight  or  ten  small  vessels,  requiring  ligature.  The  wound 
has  gaped  widely,  and  the  motion  of  the  head  is  free. 
Without  overestimating  the  chances  of  relief,  as  the  wound 
cannot  contract  to  smaller  dimensions  than  before,  and  as 
the  fibrous  and  contracting  lymph  is  entirely  removed  at 
this  point,  we  have  every  hope  for  a  repetition  of  the  improve- 
ment which  followed  the  previous  operation. 

Case  V.  Tertiary  Syphilis.  Ulcer  behind  the  Left  Leg 
on  the  Calf.  —  This  patient,  a  middle-aged,  healthy  man, 
had  chancres  fifteen  years  ago,  and  again  in  September, 
1849,  for  which  he  treated  himself,  although  subsequently 
he  took  pills  for  a  long  time  from  a  physician.  Two  months 
after  the  primary  sores,  he  had  rheumatism  of  the  right  wrist 
and  knuckles,  and  soon  after  scabs  upon  the  hairy  scalp, 
accompanied  bv  the  development  of  a  discrete  eruption  of 
pimples  elsewhere  on  the  body.  Some  of  these  pimples  be- 
came large,  and  covered  with  scabs.  The  left  leg  was  subse- 
quently the  seat  of  a  considerable  ulceration,  which  attained 
the  size  of  the  palm  of  the  hand,  and  was  preceded  by  a  sub- 
cutaneous tubercle.  1  will  only  remark  of  this  case,  that  its 
progress  is  somewhat  anomalous.  The  deeper  forms  of  cuta- 
neous eruption,  the  tuberculo-crustaceous  eruption  of  transi- 
tion from  secondary  to  tertiary  disease,  and  especially  the 
tertiary  ulcer  of  the  skin,  resulting  from  tumeur  gommeux, 
usually  belong  to  a  later  period  of  the  affection  than  that  at 
which  they  have  been  manifested  in  this  case.  It  is  hardly 
worth  while  to  go  back  fifteen  years  for  the  primary  affection, 
though   a   period   even  as  long  as  twenty  years  has   been 


NOTES   FROM   CLINICAL   LECTURES  207 

assigned  as  a  prodrome  of  tertiary  disease.  There  is  reason  to 
believe  that  the  patient  has  undergone  mercurial  treatment, 
which  may  account  for  the  absence  of  some  of  the  usual  forms 
of  secondary  affection.  The  view  which  has  been  adopted 
in  relation  to  this  case  is  confirmed  by  the  rapid  cicatrization 
of  the  ulcer  under  the  specific  treatment  of  tertiary  disease, 
viz.  the  iodide  of  potassium  in  considerable  doses,  here 
increased  slowly  from  five  to  ten  and  fifteen  grains,  three 
times  a  day,  and  for  a  length  of  time.  The  patient  will  soon 
be  well. 

November  16,  1850.  Case  I.  Traumatic  Ectropion.  —  A 
middle-aged  man,  in  good  health,  stated  that,  nine  years  ago, 
he  first  perceived  a  small  pimple  upon  the  lower  lid  of  the 
eye,  which  gradually  increased  until  it  had  attained  the  size 
of  a  large  pea.  A  few  months  ago  it  was  treated  with  caustic 
by  a  quack,  when  the  entire  eye  became  inflamed  to  a  degree 
resulting  in  its  disorganization  and  in  its  adhesion  to  the 
remaining  fragment  of  the  lower  lid.  The  lid  is  everted, 
and  in  this  position  suspended,  tense,  between  the  eyeball 
and  cheek;  the  patient  wearing  a  poultice  over  the  whole, 
for  the  relief  it  affords  him.  In  this  case  the  ocular  glebe 
Avas  incised  for  the  purpose  of  allowing  the  escape  of  its  use- 
less contents,  and  in  the  hope  of  inducing  by  its  atrophy  a 
contraction  and  diminution  of  the  exposed  conjimctival  sur- 
face.    This  was  done  by  Dr.  Hayward,  whose  patient  he  was. 

Case  II.  Inguinal  Hernia.  Treatment  by  Injection.  —  This 
subject  seems  to  possess  some  little  general  interest.  The 
disease  is  common,  and  the  surgeon  is  often  applied  to,  to 
know  how  far  it  may  be  cured  by  injection.  This  method 
of  treatment  is  not  new.  In  his  work  on  Operative  Surgery, 
published  in  1846,  Dr.  Pancoast  states  that  he  had  employed 
it  eleven  years  before  that  date.     The  operation  consisted  of 


208  NOTES  FROM  CLINICAL  LECTURES. 

an  injection  into  the  hernial  sac  of  a  stimulating  fluid,  by 
means  of  a  minute  trocar  and  canula,  to  which  a  syringe 
was  attached.  This  writer  mentions  Lugol's  solution  of 
iodine,  or  the  tincture  of  cantharides,  in  quantity  from  half  a 
dram  to  a  dram,  as  the  injections  used.  Neither  is  there 
anything  new  in  attempts  to  obliterate  the  ring  by  adhesion 
or  destruction  of  the  sac.  Such  were,  in  the  latter  part  of  the 
last  century,  the  ligature  or  excision  of  the  sac  and  testis, 
by  which  "the  Bishop  of  St.  Papoul  found  that  more  than 
five  hundred  children  had  been  castrated  in  his  diocese  " ; 
and  the  royal  stitch,  which,  embracing  the  sac,  preserved 
the  testis  to  fulfil  its  legitimate  function  of  making  subjects 
for  the  King;  and,  later,  the  operation  which  plugged  the 
ring  with  a  part  of  the  scrotum,  and  that  which  irritated  it 
with  gelatine  threads,  or  acupuncture,  —  as  well  as  other 
devices,  which  have  been  for  the  most  part  abandoned. 

The  present  patient,  a  young  man  of  twenty-one,  healthy 
and  of  good  habits,  has  had  a  left  inguinal  hernia  for  three 
years.  Within  the  last  year  he  has  worn  a  truss,  the  hernia, 
notwithstanding,  being  often  troublesome  and  tender.  It  is 
now,  when  allowed  to  descend,  an  enterocele  of  the  size  of  a 
goose  egg,  easily  reducible,  the  ring  readily  admitting  the 
middle  finger;  and  under  these  circumstances  the  patient 
applied  for  a  radical  operation.  I  stated  to  him  that  the 
operation  was  not  dangerous;  that  it  probably  would  not 
cure  him,  though  it  might  alleviate  the  inconvenience, 
perhaps  greatly,  perhaps  not  at  all.  The  instrument  used, 
which  was  made  for  me  several  years  ago,  consists  of  a 
minute  silver  syringe  terminating  in  a  fine  tube.  The 
latter  carries  at  its  point  a  perforated  trocar,  which  serves 
at  once  to  make  the  puncture  and  to  deliver  the  injection. 
With  this  instrument,  twenty-five  drops  of  tincture  of  iodine 
were  deposited  at  the  ring  itself,  through  a  puncture  in  the 
skin  made  with  a  tenotomy  knife.     I  will  not  undertake  to 


NOTES  FROM   CLINICAL  LECTURES.  209 

say  that  I  injected  the  sac.  When  the  sac  is  thin,  I  do  not 
believe  it  possible  to  say  whether  the  instrument  enters 
the  sac,  or  whether  it  pushes  the  sac  before  it.  You  may 
perhaps  transfix  it  literally;  but  there  must  be,  in  general, 
an  uncertainty  whether  the  injection  actually  penetrates  the 
sac,  or  only  bathes  its  exterior ;  and  practically  the  differ- 
ence in  producing  inflammation,  whether  from  contact  or 
by  continuity,  can  be  of  no  great  importance.  The  result 
of  the  operation  may  be  considered  as  a  question  of  theory 
and  of  fact.  This  process  aims  to  obliterate  or  plug  the 
ring  by  an  effusion  of  adhesive  lymph.  Now  the  cause  of 
hernia  is  a  want  of  resistance  in  the  tendon;  and  as  we 
cannot  make  new  tendon,  the  question  is  how  far  lymph  is 
capable  of  supplying  its  place.  Lymph  is  a  plastic  mate- 
rial, liable  to  great  absorption,  and  having  a  tendency  to 
yield  to  pressure.  It  has  very  little  of  the  resisting  property 
of  tendon.  Most  patients  are  obliged  to  wear  a  truss  after 
the  operation  for  strangulated  hernia,  which  creates  a  con- 
siderable effusion  of  lymph.  The  tendency  of  most  irredu- 
cible hernise,  where  the  ring  is  plugged  by  its  adhering 
contents,  is  to  increase.  But  theory  should  never  stand  in 
the  way  of  fact.  If  it  were  possible  to  get  at  a  series  of 
statistics  of  this  operation,  the  result  would  be  conclusive. 
But  in  the  absence  of  these  I  will  give  the  grounds  for  my 
own  conclusions  in  respect  to  it. 

I  have  operated  in  a  number  of  cases,  sometimes  with 
relief,  sometimes  with  none.  In  one  case  of  a  young  child, 
the  pressure  of  a  light  truss  after  the  injection  of  ten  drops 
of  tincture  of  iodine,  produced  a  small  slough  of  the  integ- 
uments. 

I  have  been  not  unfrequently  applied  to,  in  common  with 
other  surgeons,  by  patients  who  had  undergone  the  operation 
once,  or  even  twice,  to  know  what  benefit  would  be  likely  to 
result  from  an  additional  operation. 

14 


210  NOTES  FROM  CLINICAL  LECTURES 

A  maker  of  trusses  informs  me  that  he  frequently  receives 
ai)plications  for  trusses  from  patients  unsuccessfully  operated 
on,  or  where  the  relief  was  only  temporary.  On  the  other 
hand,  it  is  quite  probable  that  lymph  diminishes  the  size  of 
the  tendinous  aperture  in  certain  cases,  and  sometimes  to  a 
considerable  degree.  In  fact  I  know  patients  thus  operated 
upon  several  years  ago,  wdio  believe  that  the  liability  to  a 
descent  of  the  hernia  has  been  materially  diminished,  and 
who  consider  their  condition  improved  by  the  operation, 
though  they  still  wear  a  truss. 

Now  under  these  circumstances,  if  there  be  no  great  danger 
attending  the  operation,  it  is  justifiable ;  and  I  never  heard 
of  a  fatal  result  from  it,  though  peritoneal  inflammation  is 
occasionally  quite  considerable.  So  that  a  patient  who 
desires  to  undergo  this  operation,  not  dangerous  in  itself, 
for  a  chance  of  obtaining  greater  or  less  relief  from  an  in- 
convenience, may  be  gratified. 

Case  III.  Congenital  Hypertrophy  of  the  Middle  Finger. 
Amputation.  —  This  extraordinary  deformity  occurred  in  a 
fine  healthy  young  girl  of  sixteen.  The  finger  is  truly  enor- 
mous, measuring  five  and  one  half  inches  in  length  and  the 
same  in  circumference  at  its  base.  I  removed  the  finger, 
and  with  it  about  three  quarters  of  an  inch  of  the  head  and 
shaft  of  the  metacarpal  bone. 

Case  IV.  PotVs  Disease  of  the  Spine.  Death.  — The  boy 
whom  we  saw  on  Saturday,  moribund,  died  in  the  course 
of  the  day.  He  has  been  for  some  weeks  steadily  getting 
worse,  and  within  a  few  days  quite  helpless,  sleeping  most 
of  the  time  except  when  roused.  I  have  at  all  times  refrained 
from  minutely  examining  his  back,  as  he  was  beyond  the 
reach  of  art,  and  the  great  object  was  to  make  him  com- 
fortable.    He  entered  the  Hospital  on  the  10th  of  October 


NOTES  FROM  CLINICAL  LECTURES.  211 

last,  and  his  back  at  that  time  presented  an  angular  curva- 
ture of  about  115°,  the  prominent  vertebrae  being  the  third 
and  fourth  lumbar.  This  deformity  showed  itself,  as  the 
patient  states,  six  years  ago,  but  he  has  had  no  especial  pain 
or  disability  till  within  a  few  weeks.  Seven  weeks  ago  a 
swelling  upon  the  left  side  of  the  rectum  broke,  discharging 
])us.  An  abscess  was  also  detected  at  the  time  of  the  pa- 
tient's entrance,  above  the  projecting  vertebra  and  to  the 
right  side,  which  opened  spontaneously  and  with  profuse 
discharge  a  week  before  death.  There  was  also  marked  ten- 
derness over  the  sixth  and  eighth  dorsal  vertebrae.  It  is  a 
striking  feature  in  this  case,  that  so  long  a  period  should  have 
elapsed  between  the  original  appearance  of  the  deformity  and 
the  subsequent  grave  symptoms.  This  is  unusual,  but  some- 
times happens.  To  account  for  the  recent  and  large  secre- 
tion of  pus,  we  may  suppose  either  that  the  inflammatory 
action  of  disease,  which  had  been  for  six  years  nearly  sta- 
tionary, was  suddenly  renewed,  or  that  it  had  invaded  the 
bodies  of  other  vertebrse.  The  last  hypothesis  receives  some 
confirmation  from  the  position  of  the  pus  in  the  lumbar  region, 
which  was  a  little  above  the  original  lesion,  not  having  grav- 
itated as  usual  to  a  depending  point  below  it ;  and  also  from 
the  tenderness  of  the  middle  dorsal  vertebrae.  These,  how- 
ever, as  yet  presented  no  deformity;  and  both  foci  of  the 
disease,  if  there  were  two,  doubtless  contributed  to  the  supply 
of  pus  which  was  delivered  at  the  fistulous  openings;  in 
the  one  case  at  the  seat  of  the  disease,  in  the  other  upon  the 
lower  part  of  the  nates,  having  probably  escaped  from  the 
cavity  of  the  pelvis  by  the  sciatic  notch. 

November  25,  1850.  Melioerous  Ct/st  in  Forehead.  Opera- 
tio7i.  — This  patient,  a  healthy  young  man,  about  twenty-five 
years  of  age,  and  from  the  wards  of  Dr.  Hayward,  presented 
a  tumor  about  the  size  of  a  horse-chestnut  over  the  left  eye- 


212  NOTES  FROM  CLINICAL  LECTURES. 

brow.  He  stated  that  it  had  existed  from  birth,  but  that  it 
had  doubled  its  size  within  a  few  months.  Upon  examina- 
tion, it  proved  to  be  moderately  soft  and  fluctuating;  and 
from  its  "feel,"  might  have  been  a  bag  of  fluid,  or  a  common 
fatty  tumor.  And  yet  you  could  be  tolerably  sure  of  making 
a  correct  diagnosis  in  this  case.  In  the  first  place,  a  sac  of 
any  other  fluid  than  the  caseous  matter  which  this  proved  to 
contain  is  very  rare  in  this  locality.  For  example,  a  cyst 
in  the  cellular  tissue  containing  pure  serum,  or  glairy  fluid, 
is  quite  rare.  Neither  is  chronic  abscess  likely  to  exist 
from  birth,  or  without  some  of  the  inflammatory  symptoms 
which  were  wanting  here.  Fatty  tumor,  which  is  sometimes 
fluctuating,  has  generally  a  lobulated  feeling  somewhere, 
which  this  had  not.  I  examined  this  patient  carefully  at  my 
house  before  he  entered  the  Hospital.  There  was  a  uniform 
fluctuating  mass  above  the  brow,  bounded  at  its  inner  side 
by  a  remarkably  long  vertical  ridge.  Now  several  years  ago 
I  removed  a  similar  congenital  tumor  from  a  child  of  three 
years  of  age,  situated  deep  beneath  the  temporal  muscle,  and 
found  it  embedded  in  just  this  way  in  a  depression  which  it 
had  formed  for  itself  in  the  temporal  bone ;  so  that  these 
tumors,  when  congenital,  may  embed  themselves  at  a  very 
early  period  in  the  thin,  soft  adjacent  bone,  remaining,  as 
in  the  present  case,  comparatively  inactive  for  a  number  of 
years,  and  suddenly  in  a  few  months  expanding  so  as  entirely 
to  outgrow  their  original  accommodations.  When  a  cyst  thus 
rapidly  increases,  the  enlargement  in  several  that  I  have  re- 
moved seemed  to  be  from  an  increase  of  its  serous  rather 
than  its  solid  contents.  In  this  case  it  was  not  so.  The 
whole  material  had  increased  in  quantity. 

Apart,  however,  from  any  })eculiar  features,  encysted 
tumors  are  very  common  in  this  region;  upon  the  lid,  in 
the  orbit,  and  about  it;  so  that  a  tumor  here,  which  presents 
nothing  incompatible  with  the  hypothesis,  and  which  suggests 


NOTES  FROM  CLINICAL  LECTURES.  213 

no  other  especial  growth,  may  be  fairly  set  down  as  of  this 
character. 

By  "  encysted  tumors, "  I  mean  a  distinct  bag  or  cyst,  con- 
taining this  peculiar  caseous,  soft  white  material.  Serous 
cysts  (if  we  except  "  hydrocele  of  the  neck  "  )  are  excessively 
rare ;  cysts  containing  glairy  fluid  (if  we  except  the  bursse) 
still  more  so.  Nor  should  the  term  "  encysted  "  be  applied 
to  those  hard  or  fatty  tumors  which  happen  to  get  surrounded 
by  a  little  condensed  cellular  tissue,  from  which  they  "  peel 
out. "  The  true  "  encysted  tumor "  is  very  common,  and, 
being  quite  distinct  from  other  growths,  should  have  a  mo- 
nopoly of  the  name.  It  is  said  to  contain  either  atheroma  or 
meliceris,  —  very  ancient  words,  which  often  convey  no  dis- 
tinct idea.  Yet  these  terms  are  really  very  descriptive  of 
the  qualities  of  their  contents,  the  former  signifying  pap, 
the  latter  honey-wax ;  by  which  is  meant,  I  believe,  not  clear 
honey,  but  chilled  or  frozen  honej^,  which  it  greatly  resem- 
bles. They  are  in  pathology  nearly  identical ;  but  atheroma 
readily  mingles  with  water ;  meliceris  is  waxy,  sebaceous,  or 
oily,  and  sheds  water.  Atheroma  is  a  watery  fluid,  filled 
with  little  plates  or  fragments  of  epidermic  material,  some- 
times as  large  as  grains  of  rice,  and  of  a  semi-translucent 
white.  Under  the  microscope  it  shows  numberless  epithe- 
lial scales,  of  which  these  masses  are  composed ;  sometimes 
nucleated,  sometimes  not,  and  often  very  irregular.  In  meli- 
ceris, on  the  other  hand,  though  there  may  be  serum  present 
in  small  quantity,  yet  the  cells  adhere  to  each  other  by  a 
tenacious  sebaceous  matter,  or  concrete  oil,  and  in  at  least 
four  among  the  tumors  of  this  sort  which  I  have  removed, 
and  of  which  I  have  retained  a  careful  microscopic  record, 
there  were  no  scales,  but  in  their  stead  beautiful  translucent 
oval  cells,  a  few  of  them  nucleated;  and  occasionally,  as  a 
few  in  this  case  did,  presenting  irregularities  in  form,  and 
some  being  of  minute  size.     Their  usual  diameter  is  rather 


214  NOTES   FROM  CLINICAL  LECTURES. 

less  than  that  of  an  epithelial  scale,  and  they  are  seen 
embedded  in  and  inseparable  from  the  granular  sebaceous 
oily  mass  when  the  field  is  filled  with  water ;  but  substitute 
oil  for  the  water  between  the  glasses,  and  these  granules 
are  at  once  dissolved,  the  cells  coming  out  clear  and  clean 
into  the  field,  and  being  the  most  truly  beautiful  cells  I  have 
ever  met  with  among  morbid  growths.  They  are  almost 
hyaline,  and  may  be  rolled  about  like  little  bladders.  In 
one  case  they  partially  collapsed  upon  the  contact  of  oil,  as 
by  an  instantaneous  exosmose.  The  gross  mass  looks  like 
lard  at  ordinary  temperatures,  and  is  sticky  and  greasy  to 
the  touch. 

The  cyst  of  meliceris  and  atheroma  is  sometimes  lined 
with  a  beautiful  epithelium.  Sometimes  the  epithelium  is 
irregular  and  rough.  In  two  cases  of  meliceris,  at  least,  the 
epithelial  lining  was  only  partial,  the  rest  of  the  surface 
being  moist  and  divested  of  integument.  This  last  character 
may  perhaps  have  some  influence  in  determining  the  quality 
of  the  secretion;  whether  watery,  or  sebaceous  and  waxy; 
whether  epithelial  scales,  or  those  large  and  beautiful  epithe- 
lial cells. 

These  cysts  sometimes  attain  great  size.  I  have  one  that 
I  removed  from  the  shoulder  which  held  a  large  tumblerful 
of  atheroma.  Sometimes  they  point  and  burst,  subsequent 
inflammation  then  obliterating  the  sac,  or  it  remains  open. 
But  usually  the  whole  sac  requires  extirpation,  as  in  this 
case,  where,  after  puncture,  the  sac  was  dissected  out  by  Dr. 
Hayward.  A  small  portion  when  left  is  sometimes  obliter- 
ated, but  sometimes  gives  rise  to  new  secretion;  so  that  it  is 
better  in  operating  to  wait  for  the  bleeding  to  cease,  and  to 
explore  the  wound  for  the  whole  sac ;  especially  in  the  lid. 
where  the  bleeding  at  first  obscures  everything.  About  the 
orbit  these  growths  are  very  liable  to  be  adherent  to  the  bone ; 
and  congenital  tumors  thus  situated  have,  in  several  cases 


NOTES   FROM   CLINICAL   LECTURES.  215 

which  I  have  recorded,  proved  meliceric  and  not  atheroma- 
tous. Of  their  cause,  we  know  nothing.  Astley  Cooper 
thought  that  they  were  obstructed  sebaceous  follicles.  Lebert 
states  that  they  contain  all  the  products  of  these  follicles. 
This  they  certainly  do,  and  often,  in  addition,  hair,  either 
free  or  attached ;  but  they  are  occasionally  deep,  and  seem 
to  me  to  have  also  other  analogies  than  those  offered  by 
the  sebaceous  follicle. 

Cases  II.  and  III.  Hydrocele.  Radical  Operation.  — 
These  two  cases  were  average  instances  of  the  disease ;  being 
each  about  the  size  of  a  small  fist,  elongated  in  their  vertical 
diameter.  As  to  establishing  a  diagnosis  from  the  external 
outline,  pear-shaped  or  other,  which  these  accumulations 
of  riuid  present,  it  is  very  uncertain.  Their  great  test  is 
translucency.  A  common  hydrocele  is  translucent.  These 
were  perfectly  so.  When  I  first  examined  the  elder  of  these 
patients,  I  felt  a  distinct  series  of  irregularities  upon  the 
posterior  surface  of  the  sac,  like  indurated  veins  of  varix,  or 
some  other  unfrequent  accompaniment  of  the  affection ;  but 
transmission  of  light  showed  that  there  was  no  varix,  and  that 
the  convoluted  sensation  was  only  accidental  and  in  the  fibrous 
parietes.  These  things  are  sometimes  very  deceptive.  I  once 
treated  a  perfectly  hard  and  knobbed  string  of  tumors  upon 
the  cord  by  leeches,  there  being  some  pain,  and  as  I  had 
no  doubt  of  their  solid  character.  There  was  no  approach 
to  fluctuation.  As  a  mere  experiment,  when  I  saw  the 
patient  again  I  placed  a  lamp  behind  them,  and  they  proved 
to  be  perfectly  transparent,  constituting  "hydrocele  of  the 
cord,"  the  unobliterated  tube  which  the  testis  drags  after  it 
to  the  scrotum.  To  examine  properly,  you  should  grasp  the 
scrotum  behind,  and,  drawing  the  skin  tense  over  the  tumor, 
look  through  your  hand,  or  a  roll  of  paper,  or  a  stethoscope 
placed  upon  the  shaded  side  while  the  other  is  illuminated  by 


216  NOTES   FROM   CLINICAL   LECTURES. 

a  lamp,  or,  what  is  better,  by  strong  sunlight.  And  it  should 
be  borne  in  mind  that  pus,  or  bloody  fluid,  or  walls  greatly 
thickened  with  lymph,  are  not  unfrequent  and  are  opaque. 
They  must  be  judged  from  other  evidence.  You  may  have 
noticed  that  in  the  elder  of  these  patients  the  testis  seemed  to 
be  a  distinct  mass  appended  to  the  bottom  of  the  tumor, 
instead  of  being,  as  usual,  embedded  behind  it,  and  from  a 
quarter  to  a  third  of  the  way  up.  This  was  probably  from 
an  accidental  adhesion  of  the  tunica  vaginalis  to  the  front 
of  the  testis,  which  prevented  the  sac  from  being  distended 
downwards  and  forwards. 

The  history  of  these  two  cases  illustrates  well  the  varying 
progress  of  the  disease.  The  affection  of  the  middle-aged 
seaman  dates  from  twelve  years,  and  has  never  been  operated 
upon.  That  of  the  young  man  of  twenty-one  is  of  only  three 
years'  duration,  and  I  have  drawn  the  water  from  it  twice 
before.  The  contents  of  the  former  are  a  pale  thin  serum, 
becoming  only  cloudy  upon  the  addition  of  nitric  acid;  of 
the  latter,  a  thicker  bright  yellow  fluid,  containing  abundant 
albumen,  the  whole  being  stiffened  as  you  see  by  the  acid. 

It  is  unnecessary  to  speak  of  the  numerous  methods  of 
exciting  inflammation  and  the  exudation  of  lymph  with  a 
view  to  the  obliteration  of  the  cavity.  Port  wine  with  water, 
which  sometimes  produces  sloughs  of  the  cellular  tissue,  has 
been  pretty  generally  abandoned  for  tincture  of  iodine,  which 
does  not.  I  have  often  seen  Velpeau  fill  the  sac  with  water 
containing  one  third  tincture  of  iodine.  It  was  rubbed  about 
in  the  sac  until  it  occasioned  pain,  and  then  allowed  to 
escape.  Another  way,  and  that  which  I  adopted  in  these 
cases,  is  to  inject  a  dram  of  tincture  of  iodine  in  two  or 
three  drams  of  water,  and  to  leave  the  whole  in  the  sac  for 
absorption.  This  method  seems  to  be  as  effectual  and  safe 
as  any  other  for  the  average  cases  of  the  affection  in  adults. 
You  observed  that  it  excited,  as  often  happens,  considerable 


NOTES  FROM   CLINICAL  LECTURES.  217 

pain  in  the  course  of  the  cord  and  in  the  loins,  especially  in 
the  case  of  longer  standing,  where  the  water  had  never  been 
drawn  off.  The  testis  will  probably  swell,  perhaps  largely ; 
fiocculent  serum  will  be  effused  into  the  sac,  as  into  the 
thorax  in  pleurisy,  and  when  absorbed  will  leave  correspond- 
ing adhesions  of  the  organizable  parts  of  the  albumen,  which 
is  the  object  of  the  operation. 

Case  IV.  —  In  the  corner  of  the  east  male  ward  you  saw 
on  Saturday  a  patient,  an  otherwise  robust  mechanic,  aged 
twenty-four,  with  a  remarkable  tumor  in  the  left  groin ;  a 
deep-seated  mass  as  large  as  the  two  fists,  rising  considerably 
above  the  surface,  its  base  measuring  five  by  six  inches,  and 
surmounted  with  abundant  convoluted  veins.  The  leg  of 
that  side  was  also  very  large,  the  calf  measuring  four  inches 
more  in  circumference  than  the  right.  The  whole  surface  of 
this  leg  is  purple,  with  dilated  venous  capillaries,  and  upon 
the  external  aspect  varicose  veins,  with  several  considerable 
ulcers  of  the  leg,  probably  resulting  from  them.  This  exces- 
sive oedema,  the  varix  and  ulceration,  are  doubtless  the  result 
of  compression  of  the  veins  at  the  groin,  as  the  mass  lies 
directly  upon  them,  involving  Poupart's  ligament.  From 
his  account,  the  patient  first  discovered  a  small  tumor  in  the 
groin  four  years  ago,  and  at  the  same  time  swelling  in  the 
leg,  both  of  which  have  slowly  increased;  yet  he  kept  at 
work  until  the  ulcers  appeared  four  months  since. 

What  is  the  character  of  this  tumor  ?  Upon  its  surface  is 
a  large  and  solid  handful  of  varix,  easily  compressed,  and 
leaving  no  doubt  of  its  character.  Beneath  this  is  a  mass  of 
lumps,  some  adherent  to  each  other,  others  movable,  and 
varying  from  the  size  of  a  kidney  bean  to  that  of  an  English 
walnut.  These  are  doubtless  enlarged  glands.  Exploring 
the  inguinal  ring,  we  find  it  free  from  hernial  protrusion. 
The  saphenous  opening,  as  far  as  we  can  reach  it  through 


218  NOTES  FROM   CLINICAL  LECTURES. 

the  swelled  integuments,  is  equally  free  from  crural  hernia. 
This  tumor  lacks  the  thrill  and  the  pulsation  of  aneurism, 
of  which  enlarged  glands  are  no  regular  feature.  There 
is  neither  elasticity  nor  any  lesion  elsewhere  to  lead  us 
to  suspect  chronic  abscess.  It  is  not  a  fatty  tumor.  The 
fibro-albuminous  or  sarcomatous  tumor  I  have  never  known 
to  infect  the  neighboring  glands.  There  is  no  acute  inflam- 
mation. Probability  then  settles  between  the  alternative 
either  of  a  disease  which  does  tend  to  affect  the  glands,  or 
an  idiopathic  affection  of  the  glands  themselves.  It  has 
occurred  to  me  whether  some  diseased  enlargement  of  the  leg 
may  have  infected  these  glands ;  but  I  know  of  no  such  dis- 
ease, nor  is  there  here  any  circumscribed  affection  in  the  leg 
or  thigh,  which  moreover  has  grown  much  smaller  for  ban- 
daging, while  the  ulcers  have  nearly  healed.  The  groin  is 
probably  the  seat  of  the  original  lesion,  and  the  swelled 
leg  an  effect  of  it.  Now  cancer  in  its  various  forms  infects 
the  glands  as  a  primary  disease,  or  is  secondarily  absorbed 
into  them  from  the  neighborhood ;  and  this  is  not  a  very  un- 
common place  for  it.  T  have  seen  three  cases  in  the  groin 
which  I  supposed  cancer,  in  one  of  which  it  arose  from  the 
femur  near  its  head.  But  in  those  cases  there  was  a  princi- 
pal central  lesion  to  which  the  glands  seemed  to  be  satel- 
lites. Here  we  have  a  confused  mass  of  glands  more  or  less 
distinct,  as  far  in  as  we  can  feel  them,  and  no  principal  mass 
till  we  get  very  deep.  There  is  also  less  tendency  to  mutual 
adhesion  than  I  should  think  common  in  glands  which  have 
absorbed  cancerous  cells. 

Idiopathic  cancer  of  an  absorbent  gland  itself,  in  three 
cases  I  have  seen,  in  the  neck,  inside  of  the  elbow,  and  in 
the  groin,  was  more  confined  to  the  single  affected  gland, 
which  gi-ew  to  the  size  of  a  goose  egg  and  larger,  while  the 
neighboring  glands  were  but  slightly  enlarged,  if  at  all. 
So  that  this  tumor  wants  some  of  the  usual  features  of  maliff- 


NOTES  FROM  CLINICAL  LECTURES.  219 

nant  disease.  On  the  other  hand,  what  is  called  "chronic 
inflammation  of  the  glands  "  does  present  a  very  similar 
chain  of  tumors.  They  often  occur  in  the  neck,  and  on  sec- 
tion exhibit  the  enlarged  and  red  gland  beautifully  spotted 
or  divided  with  patches  of  dense  opaque,  straw-colored 
lymph,  infiltrated  into  its  tissue.  I  have  never  identified 
glands  in  the  groin,  —  as  I  have  in  the  neck  where  they  are 
occasionally  extirpated,  —  except  as  scrofulous  abscess,  after 
they  have  become  fused  and  suppurated,  in  which  state  they 
are  brought  to  the  surgeon. 

I  think  we  may  be  satisfied  that  this  tumor  comes  into  one 
of  these  two  categories ;  but  I  believe  it  to  be  impossible  at 
present  to  decide  which.  We  shall  doubtless  know  more 
about  it  from  its  future  manifestations.  In  the  mean  time, 
the  leg  has  been  bandaged  and  placed  at  rest  in  a  horizontal 
position,  with  great  relief  and  diminution  in  size.  For  the 
present,  iodine  will  be  administered  internally,  and  cau- 
tiously applied  externally. 

December  2,  1850,  —  Case  I.  Fistula  in  Ano.  Operation. 
—  This  patient  experienced,  according  to  the  history  of  his 
affection,  a  longer  interval  than  is  common  between  the 
first  appearance  and  the  discharge  of  the  abscess.  It  de- 
veloped spontaneously  by  the  side  of  the  rectum  two  years 
ago,  and  at  the  expiration  of  two  months  projected  an  inch 
or  more  before  breaking.  It  is  often  asked  whether  an 
abscess  in  this  region  leads  necessarily  to  what  is  called 
fistula  in  ano ;  or,  in  other  words,  whether  an  abscess  may 
exist  here  without  the  usual  tendencies  of  this  troublesome 
affection.  You  will  find  in  the  books  that  a  spontaneous 
cure  is  excessively  rare.  I  have  seen  one  such  case ;  but  I 
incline  to  believe  that  there  are  surgeons  of  larger  experi- 
ence who  may  not  happen  to  have  seen  even  one.  It  was  in 
a  young  man  in  whom  a  tender  induration  at  the  outer  mar- 


220  NOTES  FROM   CLINICAL  LECTURES. 

gin  of  the  sphincter  broke  about  the  third  day.  The  probe 
entered  three  quarters  of  an  inch,  but  the  excessive  tender- 
ness of  the  part  caused  the  operation  to  be  deferred,  and  the 
opening  healed  by  the  fifth  day  after.  This  occurred  at  least 
two  years  before  the  use  of  ether,  and  the  patient  has  had 
no  trouble  since.  Such  a  case  is  rare,  and  an  abscess  by  the 
side  of  the  rectum  generally  requires  the  operation  for,  and 
practically  is,  "fistula."  If  we  adopt  Brodie's  view,  that 
this  abscess  is  always  caused  and  perpetuated  by  the  escape 
of  fasces  through  a  little  ulcer  of  the  mucous  membrane  lin- 
ing the  sphincter,  we  have  a  constant  and  peculiar  condi- 
tion connected  with  it  which  prevents  its  spontaneous  cure. 
Brodie  thinks  this  is  the  cause  of  their  duration,  rather  than 
the  friction  and  motion  of  the  sphincter  and  levator ;  and,  as 
a  natural  result,  urges  the  necessity  of  finding  this  internal 
perforation,  and  of  making  the  incision  through  it  in  order 
to  obliterate  it.  Against  these  views  of  this  most  distin- 
guished authority  it  may  be  alleged  that  a  surgeon  is  gener- 
ally called  upon  to  operate  without  the  "  three  or  four  exam- 
inations "  which  he  finds  to  be  sometimes  necessary  for  the 
discovery  of  the  internal  orifice;  and  that  in  the  event  of 
not  finding  it  it  is  common  to  perforate  the  mucous  mem- 
brane with  an  artificial  opening,  and  that  such  cases  usually 
get  perfectly  well.  In  this  case  the  internal  orifice  was 
readily  found  at  its  usual  place  about  half  an  inch  above  the 
external  sphincter.  A  few  days  ago,  in  another  case,  I  found 
the  ulcerated  orifice  in  a  less  common  position,  at  the  extreme 
head  of  the  sinus  and  of  the  sphincter,  and  opening  into  the 
dilated  gut  above.  The  usual  position  of  the  internal  fistula 
indicating  the  place  for  exploration,  and  the  hole  being 
found  and  the  incision  made,  it  remains  to  be  settled  what  is 
to  be  done  with  the  upper  part  of  the  sinus,  which,  as  in  this 
case,  often  runs  an  inch  highei-  up.  Brodie  advises  that  it 
be  left.     This  one  I  slit  with  scissors  to  the  extent  of  half  an 


NOTES  FROM   CLINICAL  LECTURES.  221 

inch,  as  it  was  deep,  and  there  was  no  especial  reason  for 
not  placing  it  in  the  category  of  other  sinuses.  In  fact,  it 
is  common  to  divide  such  a  sinus  with  caution.  There  is  a 
chance  of  hemorrhage  from  vessels  you  cannot  reach.  But 
when  the  wall  is  thin,  you  may  feel,  with  the  finger  in  the 
anus,  the  hemorrhoidal  arteries  beating  in  its  substance,  and 
avoid  them.  There  were  none  here;  but  in  a  case  a  year 
ago,  where  such  a  vessel  was  high  up,  directly  below  the 
upper  orifice,  I  passed  a  wire  of  pure  silver,  which  will  twist 
without  breaking,  through  the  latter,  and  let  it  cut  its 
way  out.  Then  there  are  not  unfrequently  sinuses  outside, 
extending  laterally  upon  the  nates,  sometimes  to  the  tuber- 
osity, or  in  front  to  the  scrotum.  A  recent  or  inflamed  one 
may  be  left  to  itself,  the  sphincter  being  divided;  but  a 
chronic  or  indurated  one  had  better  be  laid  open,  as  in  the 
present  case,  where  such  a  sinus,  opened  by  the  patient 
himself  with  a  penknife,  had  been  frequently  touched  with 
caustic  and  become  greatly  indurated.  The  patient,  who 
seems  to  have  studied  the  subject,  desired  that  it  should  be 
dissected  out ;  but  it  will  now  doubtless  granulate  on  expos- 
ure to  the  air.  The  operation,  apart  from  the  chance  of 
hemorrhage,  is,  as  you  saw,  inconsiderable.  A  finger  in 
the  anus  meets,  at  the  inner  fistula,  a  probe  passed  into  the 
sinus.  Now  you  may  follow  the  probe  with  a  narrow  blunt- 
pointed  knife,  and  make  it  cut  its  way  out,  resting  on  the 
tip  of  your  finger;  or,  what  is  easier,  and  as  I  did  in  this 
case,  drag  down  the  tip  of  the  probe  or  director  through  the 
anus,  and  slide  it  over  upon  the  opposite  side  of  the  nates. 
The  mass  is  then  exposed,  lying  upon  your  instrument,  and 
you  divide  it  as  you  please.  A  little  dry  lint  separates  the 
cut  surfaces  for  a  day  or  two  while  they  have  a  tendency  to 
unite,  and  the  wound  afterwards  requires  only  to  be  kept 
clean.  This  patient  will  doubtless  get  about  in  the  course  of 
a  fortniffht. 


222  NOTES   FROM   CLINICAL  LECTURES. 

Case  II.  Injurij  of  Finger.  Amputation. — A  middle- 
aged  woman,  otherwise  healthy,  two  years  ago  washed  her 
finger,  wliicli  was  slightly  pricked,  in  soapsuds  containing 
bedbug  poison.  The  finger  swelled  largely;  of  which  the 
rational  explanation  probably  is  to  be  found,  not  in  any 
specific  action  of  a  mineral  or  vegetable  poison,  but  in  an 
aggravation  of  some  pre-existing  tendency  to  inflammation. 
The  patient  applied  to  a  doctress  "good  in  such  cases," 
who  opened  an  abscess  with  scissors  and  poured  into  it 
alcohol. 

After  a  considerable  interval,  the  finger  came  under  proper 
treatment  in  the  hands  of  a  surgeon,  and  was  healed,  its  two 
extreme  joints  remaining  stiff.  This  unfortunate  member 
was  again  accidentally  laid  open  and  the  bone  fractured  by  a 
blow  a  fortnight  since.  The  tissue  of  the  old  cicatrix  ulcer- 
ating, as  it  easily  does,  the  parts  assumed  the  appearance  of  a 
whitlow.  Dr.  Townsend  amputated  the  finger  at  the  middle 
joint,  making  a  very  neat  flap  from  the  palmar  surface.  This 
operation  occupies  pages  in  books  upon  operative  surgery, 
and  is  a  sort  of  test  of  skill  in  the  dissecting  rooms.  It 
is  quite  convenient  to  know  that  an  incision  at  the  distal 
curved  wrinkle  on  the  back  of  the  joint  will  exactly  open  its 
cavity  without  uncovering  the  bone  too  much ;  and  that  it  is 
the  lateral  ligaments  which  resist  disarticulation.  It  is  not 
often,  however,  that  the  regularly  described  operation  will 
apply  to  a  diseased  finger.  Fingers  are  often  mashed  or 
largely  swelled ;  and  the  best  rule  I  know  is  to  get  a  good 
covering  wherever  there  is  a  bit  of  sound  and  attached  skin, 
and  then  to  divide  the  bone  with  forceps,  unless  you  are 
very  near  to  a  joint.  The  arteries  play  a  little,  but  if  the 
flap  is  stitched  or  otherwise  fixed  in  place,  and  the  finger 
compressed  with  a  narrow  bandage,  they  generally  stop 
without  tying. 


NOTES  FROM  CLINICAL  LECTURES.  223 

Case  III.  Tumor  in  the  N'ose.  Operation.  —  This  may  be 
called  a  tumor  of  the  nose,  for  it  certainly  is  not  anything 
else.  It  is,  as  far  as  I  know,  anomalous,  and  is  a  most 
extraordinary  affair.  It  came  like  a  polypus,  and  looked 
like  one;  but  it  certainly  is  no  polypus.  The  woman  is 
about  forty  years  of  age,  and  has  been  otherwise  healthy, 
but  within  a  few  months  she  has  lost  flesh.  Her  attention 
was  called  to  the  pain  in  the  nasal  and  ethmoid  bones  about 
nine  years  ago,  when,  after  a  good  deal  of  suffering  and 
some  constitutional  disturbance,  a  "gathering  broke,"  and 
there  was  a  discharge  of  fetid  pus  from  the  left  nostril. 
This  occurred  at  intervals  afterwards ;  but  about  five  years 
ago  she  expelled,  by  blowing  from  this  nostril,  a  bit  of  white 
thick  soft  matter.  This  has  happened  several  times  since, 
and  twice  a  mass  of  it  as  large  as  the  last  joint  of  the  little 
finger.  This  sort  of  history  is  very  common.  There  is  a 
class  of  patients  who  are  made  very  unhappy  by  what  they 
blow  from  their  noses,  and  there  is  sometimes  disease  and 
sometimes  not.  "  White  matter  "  often  means  only  abundant 
opaque  mucus.  So  that  this  account  alone  was  quite  unsat- 
isfactory, except  that  inspection  of  the  nose  showed  what 
appeared  to  be  an  ordinary  polypus  high  in  the  left  nostril. 
The  history  of  this  growth  went  to  confirm  its  character.  It 
"came  down,"  that  is,  came  forward  and  in  sight,  a  few  weeks 
ago.  Since  last  April  it  has  been  gradually  obstructing  the 
air  on  this  side,  and  at  present  the  stoppage  is  complete ;  the 
patient  volunteering  the  statement  that  it  becomes  larger  in 
damp  weather.  Common  polypi  do  this,  and  with  the  present 
evidence  this  was  likely  not  to  prove  an  exception.  The 
operation,  as  you  saw,  was  performed  in  the  ordinary  man- 
ner. I  introduced  a  pair  of  oiled  polypus  forceps  so  as 
carefully  to  include  the  tumor,  shut  the  handles  tightly,  and 
after  one  or  two  twists  brought  out  the  closed  instrument, 
containing  in  its  grasp  what  appeared  to  be  —  nothing.    I  men- 


224  NOTES  FROM  CLINICAL  LECTURES. 

tioned,  at  the  time,  that  this  was  a  common  experience ;  that 
a  polypus  of  some  size,  when  its  contained  serum  has  es- 
caped, often  leaves  only  a  collapsed  bit  of  mucous  mem- 
brane, concealed  between  the  blades  of  the  instrument,  to 
account  for  a  considerable  obstruction  removed.  The  for- 
ceps here  showed  only  a  little  pasty  material  at  their  ex- 
tremity. They  were  again  introduced,  and  with  the  same 
result;  but  at  this  time  the  patient  blew  from  the  nose 
a  fragment  of  this  paste.  Repeated  introduction  of  the  for- 
ceps, alternating  with  the  expulsive  effort,  at  last  cleared 
the  nasal  passage  by  the  evacuation  of  two  good  teaspoonfuls 
of  the  same  material.  This  was  a  dirty  white  substance, 
perfectly  destitute  of  obvious  organization,  about  the  con- 
sistence of  white  lead,  smooth,  homogeneous,  and  with  a 
faint  smell  of  macerating  bone.  Under  the  microscope  it 
showed  only  very  minute  granular  material,  a  very  few 
small  cells  here  and  there,  and  occasionally  fragments  of 
fine  fibres;  the  whole  field  presenting  the  aspect  of  common 
tartar  taken  from  teeth  more  nearly  than  anything  I  know, 
but  without  calcareous  deposit,  and  exhibiting  only  frag- 
ments of  the  long  and  fine  fibres  found  in  tartar. 

The  question  is  then  upon  the  nature  of  the  affection.  Is 
this  polypus  alone,  mucous,  fibrous,  or  malignant?  or  is  this 
material  superadded  to  polypus,  or  connected  with  it  ?  It 
is  obviously  something  foreign  to  the  usual  history  of  the 
affection.  We  have  sometimes  calcareous  concretions  in  the 
nares,  but  apart  from  its  resemblance  to  non-calcareous  tar- 
tar, this  material  has  no  evident  affinity  of  that  sort.  The 
early  progressive  character  of  its  history  now  becomes  of 
interest,  and  we  may  infer  that  what  was  once  a  slight  is 
now  an  aggravated  lesion ;  and  we  know  that  it  was  once 
attended  with  exacerbations  accompanied  with  headache  and 
terminating  in  a  discharge  of  pus.  This  would  suggest  some 
chronic  affection  of  the   bone,  perhaps  tubercular.     But  I 


NOTES  FROM  CLINICAL  LECTURES.  225 

am  aware  of  no  regular  affection  of  the  antrum  or  ethmoid 
resulting  in  this  way,  and  it  seems  improbable  that  a  soft 
secretion  should  accumulate  in  such  quantity  in  the  nares 
without  becoming  disintegrated  and  semi-fluid  to  a  degree 
which  would  facilitate  its  escape.  With  these  speculations, 
and  preferring  to  show  a  curious  case  in  its  actual,  though 
it  may  be  temporary  aspect,  I  leave  it  for  the  present. 

Monday,  December  16,  1850.  The  Case  of  Hernia'^  treated 
by  an  injection  into  the  ring  of  thirty  drops  of  the  tincture 
of  iodine,  left  the  Hospital  "well,"  in  three  weeks  after  the 
operation.  Before  the  operation,  the  intestine  came  down 
during  exertion,  even  with  a  truss ;  and  if  the  truss  was 
removed,  it  slipped  out  at  once,  without  effort.  When  the 
patient  left,  he  could,  as  you  saw,  cough  in  the  erect  pos- 
ture without  his  truss,  and  not  cause  a  descent  of  the  hernia. 
During  the  first  three  days  there  was  tenderness  exactly  at 
the  ring ;  but  no  peritoneal  or  constitutional  symptoms.  He 
constantly  wore  a  bandage  or  a  truss,  and  is  now  "cured," 
if  he  will  but  remain  so.  Time  only  can  show  what  effect 
the  absorption  of  the  lymph  will  have.  On  the  other  hand, 
his  condition  has  been  undoubtedly  improved,  with  slight 
risk  and  pain,  and  less  than  three  weeks'  confinement. 

The  patient  with  anomalous  affection  of  the  nose  ^  has  been 
discharged,  considering  herself  greatly  relieved.  When  the 
coagula  had  been,  in  the  course  of  a  day  or  two,  discharged 
from  the  nostril,  the  original  "  polypus  "  showed  itself  as  a 
fold  of  thickened  mucous  membrane,  dependent  from  the  upper 
turbinated  bone.  This  was  easily  removed,  although  it  had 
not  obstructed  the  nostril,  which  had  been  already  cleared. 

Case  I.     Nasal  Obstruction.     Operation. — Another  patient 

has  left  the  Hospital  relieved  of  a  difficulty  which  seems  to 

»  See  Lecture,  November  16,  p.  207.        2  ibid.,  December  2,  p.  223. 

15 


226  NOTES  FROM  CLINICAL  LECTURES. 

have  excited  some  interest.  This  young  girl  had  been  sup- 
posed to  have  a  tumor  in  the  front  part  of  her  left  nostril ; 
said  she  had  some  pain  there,  and  that  respiration  was  not 
free.  I  found  something  reaching  from  the  vomer  over 
towards  the  left  lower  turbinated  bone,  which  it  met.  Both 
mucous  coverings  were  swelled,  and  at  their  point  of  contact 
white,  as  if  suppurating,  and  exquisitely  tender  if  touched 
by  a  probe.  In  the  other  nostril,  a  little  way  back,  there 
was  a  sudden  hollow  in  the  vomer,  which  could  be  felt  by  a 
probe  better  than  seen ;  and  this  depression  corresponded  to 
the  other  prominence.  So  that  all  I  was  able  to  make  of 
this  "tumor"  was  a  deviation  of  the  vomer,  which,  project- 
ing across  against  the  turbinated  bone,  was  ulcerated  and 
tender.  Nitrate  of  silver  was  applied  several  times,  relieving 
the  tenderness;  but  finding  that  it  was  not  effectual,  I  re- 
moved the  turbinated  bone  in  part  with  polypus  forceps,  then 
with  an  oiled  finger  forced  the  vomer  back  to  its  place,  and 
left  a  sponge  in  the  nostril  to  keep  it  there.  The  face  became 
swelled  and  painful,  and  the  patient  quite  feverish  up  to  the 
fourth  day,  when  the  sponge  was  removed.  She  then  soon 
recovered,  and  left  the  house  as  she  said  "  cured, "  the  nostril 
being  well  opened. 

Case  II.  Cluh  Foot.  Operation.  —  The  tendo  Achillis  was 
divided  by  Dr.  Hayward.  There  were  one  or  two  points  of 
interest  in  this  case.  It  was  in  a  child  of  six,  paralyzed  in 
the  lower  limbs  during  four  years,  but  recovering  the  use  of 
them  the  last  year.  Paralysis  is  a  common  cause  of  slight 
club  foot,  but  not  of  the  hopeful  forms  of  it.  In  other 
words,  the  paralysis  itself  makes  the  operation  useless.  It 
acts  unequally  on  the  flexors  and  extensors,  and  the  gastro- 
cnemius, aided  by  the  natural  position  of  the  foot,  gets  the 
advantage,  so  that  the  foot  cannot  be  flexed.  If  the  paraly- 
sis continues,  it  is  useless  to  divide  the  tendon;  but  here  the 


NOTES  FROM   CLINICAL   LECTURES.  227 

patient  could  walk.  This  limb  measured  one  inch  less,  from 
the  knee  down,  than  the  other.  This  difference  puts  some 
bad  cases  of  club  foot  beyond  the  reach  of  art.  It  is  an 
arrest  of  development,  due  in  part  to  the  traction  of  the  ten- 
dons, but  more  to  a  continuance  of  the  original  action  which 
produced  the  deformity.  Of  course,  a  muscle  may  be  greatly 
reduced  in  size  from  disease,  and  even  undergo  the  fatty  or 
fibrous  transformation,  and  still  recover  its  texture  and  tone 
after  the  foot  is  brought  straight.  But  in  the  hopeless  cases, 
the  long  bones  are  actually  shorter  and  smaller,  and  no 
orthopedic  treatment  will  restore  their  dimensions.  In  this 
case  the  heel  will  readily  come  down. 

Case  III.  Epithelial  Disease  of  Face.  Operation.  —  This 
was  a  large  pimple  upon  the  skin  over  the  malar  bone  of  an 
old  lady.  Such  a  pimple  is  very  common  on  the  face  in  old 
people,  and  it  is  important  to  know  it  by  sight.  It  is  the 
"  cancer  of  the  lip  "  occurring  elsewhere.  You  saw  here  two 
pimples,  side  by  side.  One,  the  old  lady  said,  she  did  not 
care  for ;  it  had  been  there  always.  It  was  flabby  and  pe- 
diculated.  It  was  in  fact  a  "pediculated  tumor,"  so  called, 
and  harmless.  But  the  other,  though  smaller,  gave  her 
great  pain;  it  was  only  of  a  few  years'  standing,  red,  elevated, 
and  hard.  At  its  summit  was  a  little  scab.  I  removed 
the  whole  with  the  knife,  and  by  a  long  ellipse  to  avoid  a 
pucker  at  the  extremities  of  the  united  incisions.  Bisected, 
this  tumor  was  dense  and  opaque  white,  continuous  laterally 
with  the  skin,  and  below  with  the  white  fibre  of  the  cellular 
tissue  upon  which  it  was  seated.  Under  the  microscope  it 
was  distinctly  epithelial,  like  the  lip  described  in  a  previous 
lecture,  and  just  as  capable  of  ulceration.  An  old  man 
applied  to  me  a  short  time  ago,  with  a  large  everted,  rag- 
ged, and  ulcerated  elevation  on  the  cheek,  under  the  eye, 
adherent   to   the   bone.     It   was  past  much  hope  of  benefit 


228  NOTES  FROM  CLINICAL  LECTURES. 

from  operation,  but  doubtless  was  once  an  epithelial  pimple, 
which  could  have  been  easily  and  radically  removed  like 
this. 

Case  IY.  Inverted  Toe  Nails.  Operation.  —  Many  of  you 
know  this  affection.  The  great-toe  nails  are  buried,  as  in 
this  case,  at  their  edges,  deep  in  fungous  granulations,  so 
tender  that  they  cannot  be  touched.  This  begins  gradually, 
with  a  tight  shoe,  or  an  irritable  skin,  and  a  nail  uncut  at 
the  corner.  The  flesh  gets  tender,  the  corner  cannot  be  got 
at,  and  the  affection  progresses  or  remains  stationary.  It 
rarely  improves  even  with  palliative  treatment.  I  once 
raised  a  nail  slowly,  with  lint  beneath  it,  so  that  in  a  week 
the  corner  was  cut  off,  and  the  patient  never  again  suffered." 
But  you  are  generally  obliged  to  remove  the  nail,  or  a  part 
of  it.  The  patient  is  etherized,  and  if  the  nail  is  thin  you 
thrust  one  blade  of  a  pair  of  forceps  under  it  to  the  root, 
shut  the  forceps  upon  the  nail,  twist  first  to  one  side  and 
then  to  the  other,  and  extract  it,  as  was  done  here.  If  it  is 
thick,  first  split  it  to  the  root  with  scissors  thrust  under  it, 
and  peel  off  one  or  both  halves  from  tip  to  root  with  forceps. 
These  nails  came  out  whole,  but  the  nail  should  in  general 
be  examined  after  extraction  to  see  if  the  corners  of  the  soft 
root  are  square,  as  a  bit  is  often  left  in  at  the  edge  which 
reproduces  the  deformity.  A  new  nail  generally  appears, 
sometimes  deformed.  In  this  case.  Dr.  Hayward  removed 
three  nails. 

Case  V.  Fatty  Tumor  inside  of  Cheek.  Operation.  — 
This  middle-aged  woman  perceived  this  tumor  four  years  ago. 
Its  position,  just  inside  of  the  labial  commissure  under  the 
mucous  membrane,  is  a  common  one  for  little  sacs  contain- 
ing glairy  fluid.  This  looked  like  one,  and  fluctuated,  but 
proved  to  be  a  common  adipose  tumor  as  large  as  a  chestnut. 


NOTES  FROM   CLINICAL  LECTURES.  229 

I  removed  it  by  a  simple  incision.  The  ether  was  con- 
tinued to  this  patient  for  some  time  after  narcotism,  and 
until  she  snored;  her  pulse  being  only  reduced  a  little  in  fre- 
quency. This  thorough  dose  lasted  her  through  the  operation. 
With  a  common  dose,  she  would  soon  have  partially  waked, 
shut  her  mouth,  groaned  and  twisted  about ;  and  after  vain 
efforts  to  get  along,  we  should  probably  have  stopped  the 
operation  to  give  her  more  ether.  As  it  was,  she  slept  tran- 
quilly until  it  was  completed. 

Case  VI.  Disease  of  Antrum.  Operation.  —  This  patient 
of  Dr.  Hayward,  thirty-two  years  old,  a  year  ago  perceived  a 
swelling  just  under  the  edge  of  the  left  orbit.  It  was  opened 
and  discharged  pus.  Soon  afterward  another  opening  thought 
to  be  a  gumboil  formed  spontaneously  over  the  second  molar ; 
but  a  copious  and  daily  discharge  of  pus  at  this  point  dis- 
credited the  idea.  On  applying  to  a  surgeon,  a  probe  was 
passed  into  one  opening  and  out  of  the  other,  traversing  the 
antrum.  Since  then,  the  antrum  is  said  to  have  been  punc- 
tured twice,  and  a  seton  to  have  been  passed  once.  Lastly, 
foetid  pus  has  been  and  is  now  blown  from  the  nostril. 

Here  is  a  well  marked  affection  of  the  antrum ;  and  atten- 
tion may  be  directed  on  the  one  hand  to  the  mucous  mem- 
brane and  bone  of  the  cavity  itself,  and  on  the  other  to  the 
fang  of  a  tooth  and  abscess  of  the  gum,  as  the  usual  causes 
of  such  purulent  accumulations  in  this  sinus.  Here  the 
first  pus  escaped  near  the  orbit,  where  there  is  now  a  scar, 
and  the  discharge  is  foetid,  considerations  which  direct 
us  to  the  antrum  and  to  the  bone.  It  is  a  case  difficult  of 
treatment.  The  patient  was  desirous  of  an  opening  into  the 
cavity,  which  Dr.  Hayward  made  by  boring  through  the  thin 
shell  just  above  the  second  molar  tooth.  Some  of  you  may 
remember  a  similar  case  in  my  wards  last  year.  Great  pain 
and  tension  on  the  left  side  was  then  relieved  by  tapping 


230  NOTES  FROM  CLINICAL  LECTURES. 

the  antrum  in  this  same  place.  Pus  escaped,  and  the  patient, 
encouraged  by  the  success,  was  very  desirous  to  have  the 
other  side  opened,  there  being  an  uneasy  feeling  there.  1 
advised  him  against  it,  for  want  of  indications ;  but  subse- 
quently, as  the  operation  is  in  reality  a  small  affair,  yielded 
to  his  solicitation.  There  was  no  pus,  and  the  jaw  swelled 
largely.  In  the  first  instance,  the  opening  evacuated  pus  and 
was  a  relief.  In  the  second,  it  was  an  injury  to  a  compara- 
tively sound  part,  and  was  at  once  felt.  As  to  the  operation, 
if  you  do  not  perforate  the  socket  of  a  tooth,  find  the  base 
of  the  zygomatic  arch  above  the  molars,  incise  the  mucous 
membrane  freely,  and  expose  the  bone ;  otherwise  the  blood 
is  apt  to  distend  the  tissues,  and  make  the  landmarks 
obscure.  You  then  bore  through  the  thin  bone  with  any 
convenient  instrument.  I  have  used  a  three  or  four  square 
pyramidal  point. 

Cases  VII.  and  YIII,  Hydrocele.  —  Two  more  cases, 
illustrating  the  varieties  of  this  affection.  One  in  a  young 
man,  and  of  three  or  four  years'  standing;  the  other  in  an 
old  man,  and  of  eight  or  ten  years'  duration.  The  former  and 
smaller  had  a  constricted  middle,  giving  it  an  hour-glass 
shape.  The  latter  was  the  longest  and  narrowest  I  have 
seen,  extending  from  the  ring  to  the  bottom  of  the  scrotum, 
nearly  seven  inches,  and  only  two  or  three  inches  in  diam- 
eter. These  forms  are  accidental ;  both  were  translucent. 
The  small  one  was  injected  with  a  dram  of  tincture  of 
iodine  and  a  dram  of  water,  of  which  half  was  withdrawn. 
The  other  operation  was  only  palliative.  It  is  generally  not 
worth  while  to  expose  a  very  old  person  to  the  risk  of  inflam- 
mation, though  I  have  operated  upon  a  man  over  eighty  by 
incision,  and  successfully;  yet  it  is  generally  better  not  to 
do  so.  As  an  example  of  the  effect  of  the  palliative  opera- 
tion I  may  mention  the  case  of  a  man  of  nearly  ninety,  whom 


NOTES  FROM  CLINICAL  LECTURES.  231 

I  tapped  six  years  ago,  and  only  twice  since.  The  fluid  col- 
lected slowly,  and  the  risk  or  pain  of  the  puncture  was  small. 
You  can  diminish  the  pain  by  thrusting  in  the  instrument 
suddenly,  not  slowly.  Of  course  you  make  the  sac  tense  and 
thin,  avoid  the  testicle,  and  guard  the  canula  with  your 
forefinger  at  a  short  distance  from  the  point  to  prevent  it 
from  plunging  too  deeply.  A  patient  who  had  once  been 
operated  upon  slowly  remarked  to  me,  after  this  sudden 
puncture,  that  he  must  have  been  tapped  before  with  a  screw 
auger.  Another  point  in  the  radical  operation  is  to  carry 
the  canula  well  home  into  the  sac,  and  to  hold  it  there  by 
pinching  the  skin,  otherwise  you  may  inject  the  cellular  tis- 
sue instead  of  the  cavity  of  the  tunica  vaginalis. 

The  other  two  patients  have  gone  out  well,  both  of  them  in 
two  and  a  half  weeks  from  the  operation.  In  one,  there  was 
at  the  end  of  the  first  week  a  distinct  crepitus  on  pressure  of 
the  sac,  no  doubt  from  the  rupture  of  little  cells  of  lymph 
containing  water.  This  is  interesting,  in  connection  with  a 
rare  and  exceptional  subcrepitus  due  to  the  same  cause  in  the 
pleura,  and  which  is  to  be  distinguished  from  the  moist  rales 
of  the  pulmonary  cells  and  tubes. 

Case  IX.  Stricture  of  the  (Esophagus.  Dilatation.  —  The 
pathology  of  this  affection  we  reserve  for  another  day.  The 
difficulty  of  passing  the  probang,  to  those  unaccustomed  to 
its  use,  consists  mainly  in  its  being  brought  up  hard  against 
the  vertebras  behind  the  pharynx,  if  the  instrument  is  stiff. 
To  avoid  this,  the  head  is  thrown  well  back,  and,  if  need  be, 
a  finger  of  the  left  hand  is  carried  past  the  epiglottis  to  bend 
and  guide  the  instrument  in  the  oesophagus.  By  doing  this, 
you  will  avoid  the  danger  of  pumping  a  pint  of  broth  into 
the  lungs  with  a  stomach  pump,  as  was  once  done. 


232  NOTES  FROM  CLINICAL  LECTURES. 

January  20,  1851.  Case  I.  Fattij  Tumor  beneath  Fascia. 
—  The  first  patient  upon  wliom  you  saw  an  operation  per- 
formed on  Saturday  was  a  boy  with  a  large  tumor  extending 
round  the  arm  in  the  deltoid  region.  It  was  of  seven  years' 
gradual  growth,  and  had  now  become  bulky  and  inconvenient. 
It  offered  some  quite  unusual  features.  Large  fatty  tumors 
are  common  enough  in  this  region.  I  removed  one  weighing 
four  pounds  and  three  quarters  from  the  arm  of  an  old  lady 
who  was  soon  quite  well.  "Shoulder-strap  tumors,"  which 
lie  over  the  outer  triangle  of  the  neck,  are  popularly  supposed 
to  be  produced  by  the  rubbing  of  the  dress  upon  the  shoul- 
der, and  are  of  this  nature.  The  back  is  a  common  place  for 
them,  and  the  female  breast  also.  In  short,  they  grow 
almost  everywhere,  and  directly  under  the  skin.  I  had  one 
patient  in  whom  the  existence  of  six  or  eight  at  various 
points  showed  the  disease  to  be  constitutional.  From  all 
localities  the  removal  of  the  fatty  tumor  is  usually  a  small 
matter,  excepting  perhaps  in  the  back  of  the  neck.  The  mass 
lies  in  the  cellular  tissue ;  and  where  this  is  lax,  by  distending 
it,  the  tumor  grows  with  few  lobes ;  but  where  the  surround- 
ing fibres  are  dense,  they  cut  it  up  into  numerous  lobes.  Now 
the  fatty  tumor  has  a  habit  of  getting  through  an  aperture  in 
the  cellular  tissue  or  anything  else,  and  of  growing  upon  the 
other  side  into  a  lobe  too  large  to  be  drawn  back  through  the 
same  hole,  so  that  you  must  cut  or  tear  the  band  of  fibres  at 
the  neck  of  each  lobe,  and  then  the  whole  mass  is  very  readily 
and  neatly  turned  out  of  its  bed.  But  suppose  the  cellular 
tissue  to  be  so  dense  and  close,  as  about  the  lig amentum 
nuchce,  that  you  cannot  tear  it,  while  for  the  same  reason 
the  tumor  has  been  cut  up  into  a  great  number  of  little  lobes, 
each  held  by  its  neck  in  a  little  cavity ;  to  dissect  out  all 
these  would  be  endless,  and  you  are  obliged,  as  has  twice 
occurred  to  me,  to  take  out  the  whole  mass  from  the  back  of 
the  neck,  invested  with  the  cellular  tissue.     It  is  quite  like 


NOTES  FROM  CLINICAL  LECTURES.  233 

removing  a  breast,  but  less  easy  because  there  is  more  resist- 
ance, and  this  even  where  the  tumor  has  previously  seemed 
to  be  very  loose  and  movable.  Elsewhere,  cut  well  down 
upon  the  tumor;  keep  it  dissected  clean;  cut  on  the  tumor 
and  not  into  its  neighborhood,  and  you  will  have  no  diffi- 
culty. In  the  present  case  you  saw  six  inches  of  the  brachial 
artery  and  vein  dissected  quite  clean  and  exposed.  You 
often  hear  of  large  vessels  being  exposed  in  the  removal  of  a 
tumor.  Do  not  get  the  idea  that  they  are  purposely  denuded, 
or  that  such  a  dissection  is  made  with  the  intention  of  enu- 
cleating them.  It  is  not  so,  and  you  will  readily  see  how  it 
happens.  A  tumor  grows  beneath  the  fascia,  and  presses 
upon  the  neighboring  cellular  tissue,  which  is  absorbed  be- 
fore it  until  in  fact  it  lies  directly  against  a  large  artery 
and  vein.  Now  you  will  find  that  in  dissecting  you  can  often 
draw  the  tumor  away  from  these  vessels,  so  that,  always  keep- 
ing the  edge  of  your  knife  against  the  tumor,  it  may  perhaps 
never  be  nearer  to  the  vessels  than  an  inch ;  and  yet  when 
the  mass  is  out,  and  you  examine  the  bed  in  which  it  laid, 
you  will  find  the  large  artery  and  vein  just  as  close  to  the 
surface  as  they  were  to  the  tumor;  perhaps,  as  in  this  case, 
bare,  and  directly  upon  the  surface. 

The  present  tumor  extended  quite  round  the  arm,  beneath 
the  long  head  of  the  triceps,  and  on  the  inside  had  pushed 
under  the  brachial  artery  and  vein.  It  was  also  traversed 
by  an  artery  as  large  as  the  facial,  and  indented  by  the  in- 
ternal cutaneous  nerve.  It  began  small,  near  the  insertion 
of  the  deltoid.  I  stated  to  you  that  it  had  all  the  features 
of  a  fatty  tumor,  large  and  fluctuating,  lobulated  outside, 
but  less  so  on  the  inner  aspect.  The  only  doubt  lay  in  the 
fact  that  fatty  tumors  do  not  belong  beneath  the  deep  fascia 
where  this  evidently  was.  They  almost  always  grow  directly 
under  the  skin.  I  never  saw  one  so  deep  before.  Yet  they 
are  recorded  as  being  found  beneath  the  trapezius,  and  even 


234  NOTES  FROM  CLINICAL  LECTURES. 

the  mamma.  So  that  in  making  the  diagnosis,  and  allow- 
ing for  its  anomalous  position,  which  rendered  it  a  little 
obscure,  I  mentioned  fatty  tissue  as  the  probable  material. 
I  made  a  long  incision  inside  the  biceps,  and  separated  the 
tumor  from  the  artery,  vein,  and  internal  cutaneous  nerve. 
A  parallel  incision  six  inches  long  was  then  made  on  the 
outer  side  of  the  arm  near  the  triceps,  and  the  chief  obstacle 
to  the  removal  of  the  tumor  found  to  be  a  close  attachment 
by  its  membraneous  septa  to  the  periosteum  itself.  These 
being  divided,  the  aperture  beneath  the  triceps  was  dilated, 
and  the  tumor  was  then  drawn  out  from  this  opening  under 
the  muscle  and  through  the  external  incision.  It  weighed 
one  pound  and  four  ounces. 

Case  II.  Disease  of  Ankle  Joint.  Amputation.  —  This 
patient,  from  Dr.  Hayward's  ward,  during  a  period  of  seven 
years  had  more  or  less  pain  and  lameness  in  the  joint. 
For  a  year  he  was  unable  to  use  the  limb,  and  during  this 
time  quite  a  number  of  fistulous  openings  communicat- 
ing with  the  joint  have  appeared;  I  believe  a  dozen, — an 
unusual  number.  The  joint  is,  you  see,  swelled  and  blue, 
and  the  leg  atrophied  almost  to  the  bones.  About  such  a  leg 
there  can  be  no  doubt.  Whatever  the  disease  may  be  called, 
—  scrofulous  disease,  pulpy,  cartilaginous,  or  synovial  de- 
generation, or  disintegrating  lymph, — there  is  practically 
very  little  hope  in  a  case  of  this  sort.  Under  favorable 
circumstances  the  diseased  cartilage  and  bone  might  become 
destroyed  down  to  a  point  which  leaves  sound  bone,  which 
in  its  turn  might  become  anchylosed.  This  is  the  only 
recovery  from  such  a  mass  of  disease.  But  in  the  mean  time 
the  pain  and  fever  are  reducing  the  patient;  the  liquor  san- 
guinis is  drained  by  the  discharge  of  pus,  and  the  strength 
gives  out.  There  is  a  peculiar  disease,  in  which  a  small 
ulceration    in    an  otherwise  apparently   sound   cartilage   is 


NOTES  FROM   CLINICAL  LECTURES.  235 

productive  of  great  pain,  and  often  compels  amputation  of  a 
limb.  But  the  present  affection,  which  is  by  far  the  most 
common  one,  exhibits  no  clean  ulceration.  You  see  in  this 
joint  a  part  of  the  cartilage  roughened;  elsewhere  more 
deeply  pitted,  and  largely  detached ;  the  bone  exposed ; 
masses  of  granulation ;  the  whole  articular  surface  greatly 
diseased,  and  very  little  or  no  sound  cartilage.  The  affec- 
tion has  also  extended  to  the  tarsal  articulations.  The 
progress  oi  this  sort  of  disease  is  usually  not  steady,  but  by 
repeated  exacerbations,  with  intervals  of  comparative  free- 
dom from  pain;  and  the  patient  may  be  reduced  so  gradually 
that  it  is  sometimes  difficult  for  the  surgeon  who  sees  the 
case  day  after  day  to  decide  the  precise  point  at  which 
treatment  should  be  abandoned,  and  amputation  resorted 
to.  Seeing  the  same  case  for  the  first  time,  you  would 
have  less  difficulty  in  making  up  your  mind. 

A  patient  greatly  reduced  by  a  diseased  joint  often  recov- 
ers rapidly  after  its  removal.  Yet  even  then  life  sometimes 
flickers  feebly  for  a  time,  and  the  patient  sinks  under  the 
shock  of  amputation.  Perhaps  the  chief  point  to  be  settled 
in  respect  of  strength  is  the  soundness  of  the  great  viscera ; 
for  with  disease  there,  and  in  spite  of  a  few  recorded  cases 
to  the  contrary,  the  case  is  almost  hopeless. 

This  limb,  long  past  the  stage  of  doubt,  was  removed  by 
Dr.  Hay  ward  by  the  circular  operation. 

You  will  hear  much  of  the  relative  advantages  of  the  cir- 
cular and  flap  operations.  But  as  there  is  so  much  diversity 
of  opinion  upon  this  point,  you  may  be  sure  there  is  no  set- 
tled best  way ;  and  as  for  the  rapidity  of  amputation,  if  ever 
it  was  a  prime  object,  with  ether  it  is  now  no  longer  so.  The 
one  thing  needful  is  skin  enough  to  cover  the  bone.  If  one 
side  of  a  limb  is  ulcerated  or  injured,  you  get  it  from  the 
other  side,  and  this  is  a  flap;  or  you  may  make  two  flaps,  — 
on  the  sides,  or  top  and  bottom,  or  as  you  please,  so  long  as 


236  NOTES  FROM  CLINICAL  LECTURES. 

you  cover  the  bone  and  do  not  waste  material ;  for  the  best 
artificial  limbs  are  now  made  with  deep  sockets,  and  the 
longer  a  stump  is,  the  better.  This  flap  was  circular,  and 
the  stump  will  be  doubtless  an  excellent  one,  reaching  two 
thirds  of  the  way  to  the  ankle.  Accidents  may  happen  to 
all  stumps.  Flaps  retract,  bones  protrude,  and  sequestra 
come  out.  But  it  the  bone  is  once  properly  covered,  nature 
has  much  more  to  do  than  the  surgeon  in  keeping  it  so.  I 
once  had  an  opportunity  to  try  the  circular  and  the  flap 
operation  upon  the  same  subject,  in  a  case  of  mortification  of 
both  legs,  after  dysentery  on  shipboard.  The  patient  was  at 
death's  door,  but  rallied  at  once  upon  the  removal  of  the  legs 
at  about  their  middle.  This  was  soon  after  the  use  of  ether, 
and  the  patient,  of  course,  slept  throughout  these  amputa- 
tions. Both  wounds  healed  by  first  intention.  The  circular 
flap  puckered  in  healing,  as  it  generally  does.  Upon  the 
other  leg,  the  long  flap  from  behind  gave  apparently  the  best 
result,  — a  handsome  rounded  stump,  with  a  linear  cicatrix. 
Yet  it  is  probable  that  a  few  years  would  make  them  much 
alike.  The  muscle  and  fat  of  a  large  flap  is  then  atrophied, 
and  the  roundness  lost.  This  T  may  state  as  also  the  view 
of  Dr.  Townsend,  whose  opportunities  for  examination  were 
frequent  during  the  last  war. 

Case  III.  Necrosis  of  the  Humerus.  Operation.  —  The  dis- 
ease in  this  case  was  of  fifteen  years'  duration.  There  were 
a  number  of  fistulous  openings  about  the  deltoid,  leading 
to  dead  bone,  and  a  large  one  also  between  the  clavicle  and 
scapula  above,  traversed  by  the  omo-hyoid  muscle,  which 
bisected  it.  Water  injected  here  was  followed  by  an  in- 
crease of  pus  at  the  lower  opening  in  the  course  of  the  day. 
I  am  unable  to  say  why  the  pus,  which  was  burrowing  about 
in  the  axilla,  should  have  made  this  large  ulceration  so  high 
up,   or  whether  it  depended  on  a  separate  cause.       As  you 


NOTES  FROM  CLINICAL  LECTURES.  237 

saw,  T  made  a  free  incision  down  to  the  bone  on  the  outside, 
and  through  the  deltoid;  waited  for  the  capillary  bleeding 
to  cease,  and  tied  a  small  vessel  or  two ;  denuded  the  bone, 
removed  with  a  trephine  upon  a  bit-stock  a  middle-sized 
disk  of  new  bone  a  quarter  of  an  inch  thick,  and  extracted 
through  the  opening  a  sequestrum  in  shape  like  a  large 
almond.  The  object  of  such  an  operation  is  to  get  at  and 
remove  a  sequestrum  which  is  confined  by  bone,  generally  of 
new  formation  and  thick.  You  feel  with  the  probe  a  bone 
unequivocally  loose  and  apparently  quite  accessible;  you 
cut  through  the  soft  parts  in  pursuit  of  it,  and  are  sud- 
denly, perhaps  to  your  surprise,  arrested  by  a  bony  wall 
with  an  aperture  only  as  large  as  a  crow's  quill,  into  which 
the  probe  passes  perhaps  half  an  inch.  The  old  way  was  to 
attack  this  with  a  chisel  and  mallet.  But  put  a  femur  into  a 
common  vise,  and  try  with  a  chisel  and  mallet  to  expose  the 
interior  of  its  shaft,  and  you  will  find  how  slowly  the  work 
goes  on.  Now  there  is  a  French  instrument  {scie  a  molette) 
which  I  have  used  for  a  number  of  years,  consisting  of  a 
small  circular  saw,  attached  to  an  iron  rod,  which  receives 
its  revolutions  from  a  bit-stock  in  the  hands  of  an  assistant. 
The  rod  is  about  two  feet  long,  and  is  broken  for  con- 
venience by  a  universal  joint.  A  hole  is  trepanned  into  the 
bone,  and  if  the  sequestrum  is  refractory,  another  hole  is  also 
trepanned  a  few  inches  distant,  and  the  circumferences  of 
each  united  by  parallel  lines,  so  as  to  make  an  oval  hole. 
This  last  is  done  by  the  circular  saw,  and  the  little  time  it 
occupies  and  the  facility  of  its  work  are  quite  striking.  1 
should  say  it  required  about  one  minute  for  ten  consumed 
by  the  old  process.  A  beautifully  symmetrical  hole  may 
be  made  in  five  minutes,  which  would  require  half  an  hour's 
work  of  the  chisel.  This  is  really  an  advantage  of  impor- 
tance. Here  are  sequestra  which  I  have  removed  in  this 
way:  a  long  one  from  the  femur;  this  one,  not  unlike  a  but- 


238  NOTES  FROM  CLINICAL  LECTURES. 

ternut  in  size  and  roughness,  from  the  left  ramus  of  the  jaw, 
and  moreover  infiltrated  with  salts  from  the  saliva.  Here 
is  a  very  remarkable  sequestrum  from  a  boy,  a  patient  of 
Dr.  Osgood  of  Saxonville,  which  is  actually  two  thirds  of 
the  humerus.  Its  upper  extremity  projected  through  the 
skin  just  under  the  axilla,  while  the  whole  articulating 
surface  at  the  elbow  was  salient  and  exposed  obliquely  out- 
wards. The  whole  looked  somewhat  like  a  large  spike,  of 
which  the  condyles  represented  the  head,  driven  in  obliquely 
at  the  elbow,  and  its  point  appearing  under  the  axilla.  And 
here  are  the  marks  of  the  boy's  penknife  upon  the  exposed 
joint,  where  he  amused  the  tedium  of  convalescence  by 
whittling  it  in  situ.  You  would  have  thought,  as  I  did, 
that  it  could  be  pulled  out  from  below  with  ease.  But  it  was 
so  bound  and  clamped  by  new  bone,  which  pinched  it,  that  I 
was  obliged  to  remove  the  last  to  some  extent  before  it 
yielded.  And  it  is  strange  that  the  boy  has  a  serviceable 
joint  at  this  day,  traversing  an  angle  of  about  45°. 

Here  is  another  sequestrum  with  a  wisdom  tooth  in  it, 
larger  than  you  would  suppose  could  be  contained  in  the 
ramus  of  the  jaw.  Necrosis  is  sometimes  rapid.  I  removed 
this  specimen  from  a  patient  of  Dr.  Dale.  It  was  elimi- 
nated in  a  few  weeks  from  the  first  metatarsal  bone  of  a 
boy,  and  is,  as  you  see,  quite  a  piece  of  its  shaft. 

This  operation  has  its  reverses.  Here  is  the  femur  of  a 
patient,  obtained  two  years  ago,  in  whose  case  the  fistulous 
opening  was  directly  in  the  track  of  the  artery.  I  therefore 
attacked  the  bone  upon  the  outside  through  the  vastus  exter- 
nus,  and  made  this  opening  into  it.  The  patient,  a  healthy 
laborer,  died  the  next  day  of  a  remarkable  affection, — a  for- 
mation of  pus  beneath  the  layers  of  deep  fascia  and  among 
the  muscles  of  the  whole  thigh,  showing  universal  inflamma- 
tion there.  Besides  which,  before  death,  the  limb  was  in- 
flated by  gas  as  in  a  decomposing  subject. 


NOTES   FROM   CLINICAL   LECTURES.  239 

There  are  a  tew  points  of  diagnostic  interest  which  should 
be  mentioned.  The  size  of  the  sequestrum  may  sometimes 
be  judged  of  by  the  enlargement  of  the  bone,  and  by  explor- 
ing it  through  different  apertures.  Yet  if  it  is  deep-seated 
and  these  signs  fail,  the  size  of  the  dead  bone  is  often 
deceptive,  and  a  very  small  sequestrum  may  give  the  idea  of 
being  large.  Its  mobility  is  sometimes  unequivocal;  and 
upon  this  point  there  are  two  signs  I  have  noticed,  not 
mentioned  in  the  books,  I  believe,  to  which  I  attach  some 
value.  One  of  these  is  the  possibility  of  causing  pus  to 
escape  from  one  fistulous  opening  by  pressing  upon  the 
sequestrum  with  a  probe  through  another  and  separate 
aperture.  How  is  this  likely  to  happen  unless  the  seques- 
trum moves  ?  Again,  pain  —  not  a  common  local  and  acute 
tenderness,  but  a  deep  and  distant  pain  —  sometimes  attends 
the  forcible  movement  of  a  large  sequestrum  by  a  probe  in  a 
fistulous  opening.  The  sequestrum  is  then  tilted  against 
soft  granulations  at  a  remote  part  of  the  cavity.  In  such 
cases,  the  sooner  the  sequestrum  is  removed,  the  better. 
The  pathology  of  necrosis  belongs  to  another  part  of  our 
surgical   course. 


240 


STELLATE  CRACK  OF  THE  RADIUS. 


STELLATE   CRACK   OF  THE   RADIUS  AT  THE 
WRIST.  1 


Dr.  H.  J.  BiGELOw  showed  the  carpal  extremity  of  a 
radius,  which  presented  on  its  articulating  surface  a  star- 
shaped  crack,  without  displacement.  Slight  corresponding 
cracks  were  seen  in  the  shaft  for  more  than  an  inch.     The 

patient  had  entered  the 
Hospital,  under  Dr.  Big- 
elow's  care,  for  other  in- 
juries, which  ultimately 
proved  fatal.  At  first, 
complaint  was  made  only 
of  lameness  at  the  wrist, 
_  like  that  from  the  effect 

of  sprain ;  but  at  the  end 
of  several  days  the  joint  exhibited  swelling  and  tenderness, 
which,  from  its  persistence,  led  Dr.  Bigelow  to  diagnosticate 
a  stellate  crack  in  the  articulating  extremity  of  the  radius 
as  the  probable  result  of  a  fall,  he  having  met  with  a  case 
two  years  before  in  which  a  patient  with  similar  symptoms, 
dying  of  other  injuries,  had  exhibited  a  crack  in  the  same 
place,  but  less  extended  than  this.  Dr.  Bigelow  remarked 
that  the  bones  of  the  wrist  doubtless  acted  as  a  wedge  to 
spread  the  corresponding  hollow  of  the  radial  extremity,  — 
and  that  this  specimen  would  explain  the  persistence  of  some 
cases  of  sprained  wrist. 

^  From  the  Records  of  the  Boston  Society  for  Medical  Improvement ; 
published  in  the  Boston  Medical  and  Surgical  Journal,  March  4,  1858. 


LEUCOCYTH^MIA.  241 


LEUCOCYTH^MIA.1 

Leucocyth^mia  is  a  term  applied  by  Bennett  to  a  condi- 
tion of  the  blood  described  by  himself, ^  and  a  few  weeks  after- 
ward by  Virchow,  characterized  by  an  excess,  sometimes 
considerable,  of  the  white  corpuscles.  This  condition  is 
usually  accompanied  by  disease  of  the  absorbent  glands,  or 
of  some  of  the  viscera  supposed  to  be  concerned  in  the  pro- 
duction of  the  elementary  constituents  of  the  blood.  But  it 
may  yet  be  a  question  whether  this  excess  of  the  white  cor- 
puscles is  a  cause  or  an  effect  of  the  visceral  disease,  or  only 
a  collateral  circumstance.  Virchow  views  it  as  a  secondary 
lesion,  dependent  upon  affections  of  the  absorbent  glands 
or  of  the  spleen ;  and  late  English  writers  adopt  his  division 
into  the  ahsorhent  and  the  splenic  variety  of  leucocythgemia, 
both  of  which  are  embraced  in  the  present  single  case.  Dr. 
Wilks  ^  makes  this  division  more  definitely  as  follows,  and 
attempts  to  found  upon  the  second  variety  a  new  disease: 
1.  Leucocythcemia  spleyiica,  characterized  by  an  excess  of  white 
corpuscles  and  an  enlarged  spleen.  2.  Ancemia  lymphatica^ 
a  name  suggested  by  the  extreme  pallor,  debility,  and  pros- 
tration of  patients  affected  with  enlarged  absorbent  glands ; 
the  writer  apparently  inferring  from  these  symptoms  a  fact 
which  might  be  difficult  to  establish  in  the  field  of  a  micro- 
scope, —  that  the  white  corpuscles  are  not  more  numerous, 
but  only  the  red  ones  less  so. 

1  Boston  Medical  and  Surgical  Journal,  February  2, 1860. 

2  Edinburgh  Journal,  October,  1845. 

3  Guy's  Hospital  Reports,  vol.  ii.,  1859. 

16 


242  LEUCOCYTH^MIA. 

To  the  surgeon  this  disease  is  interesting,  as  the  frequent 
though  not  constant  accompaniment  of  an  enlargement  of 
the  absorbent  glands,  which,  as  I  have  seen  it,  occurs  often- 
est  in  the  neck.  About  ten  years  ago,  a  gentleman  of 
middle  age  and  remarkably  robust  constitution  died  under 
my  care,  with  great  enlargement  of  the  cervical,  axillary, 
inguinal,  and  lumbar  glands,  gradually  increasing  during 
about  a  year ;  the  autopsy  showing  also  a  slight  enlargement 
of  the  spleen.  This  was  doubtless  a  case  of  the  general  char- 
acter of  that  now  reported,  but  which  passed  for  one  of 
encephaloid  disease  of  the  absorbent  glands. 

Near  the  same  time,  a  man  in  fair  health,  of  about  sixty- 
five  years  of  age,  presented  himself  with  a  single  ovoid  gland 
at  the  front  of  the  neck  sufficiently  loose  to  justify  the  opera- 
tion he  desired.  Excision  was  effected  without  difficulty, 
but  the  patient  fell  off  and  died  a  week  after.  A  few 
slightly  enlarged  cervical  glands  were  discovered  behind  the 
single  prominent  one,  and  the  autopsy  revealed  disease  of 
the  left  lumbar  glands.  No  visceral  enlargement  was  noted 
in  a  brief  examination  for  cancer;  but  the  large  gland,  of 
which  I  have  preserved  an  admirable  colored  drawing,  meas- 
ured four  by  three  inches,  and  presented  on  section  the 
appearance  hereafter  described.  Microscopically,  it  proved 
to  consist  almost  wholly  of  uniform  granulated  corpuscles, 
resembling  those  of  a  healthy  gland,  and  which  were  re- 
corded as  an  exceptional  appearance  of  encephaloid  structure. 
A  child  two  and  a  half  years  of  age  was  brought  to  me  with 
a  chain  of  very  large  glands  around  the  neck  and  in  the 
axilla,  also  one  below  the  clavicle,  all  wholly  destitute  of 
inflammation,  and  which  were  considered  to  be  encephaloid; 
the  child  died  the  next  year,  the  masses  having  continued 
to  enlarge  without  other  change. 

These  cases,  like  others  which  might  be  cited,  are  doubt- 
less examples  of  a  lesion  which  is  at  present  considered  to 


LEUCOCYTH^MIA.  243 

have  nothing  in  common  with  encephaloid  disease.  The 
peculiar  condition  of  the  blood  now  described  may  indeed 
accompany  a  cancerous  or  a  tubercular  diathesis,  with  the 
development  of  either  disease  even  in  the  glands,  but  it  is 
said  to  have  no  relation  to  them.  The  voluminous,  elastic, 
and  well  rounded  outline  of  the  glands,  moulded  one  upon 
another,  without  adhesion,  cannot  easily  be  mistaken  for  the 
hard  beaded  kernels  of  the  scirrhous  affection,  nor  for  glands 
hardened  by  chronic  inflammation,  whose  brown  interior 
contains  spots  of  whitish  lymph  or  of  cretaceous  matter. 
They  have  still  less  resemblance  to  this  scrofulous  inflam- 
mation when  tending  to  suppuration.  But,  without  inflam- 
matory adhesion  or  change,  they  show  on  section  a  uniform 
reddish  white  semi-translucent  and  tender  tissue,  of  which 
the  microscopic  elements  are  uniform  nuclei,  very  similar  to 
those  of  the  healthy  absorbent  gland,  with  the  addition  of 
abundant  white  corpuscles  or  cells  and  granules. 

At  the  same  time  it  should  be  borne  in  mind  that  certain 
tissues  are  still  regarded  as  cancerous  which  are  mainly 
composed  of  minute  and  uniform  granulated  cells,  and  which 
strongly  simulate  in  their  gross  and  microscopic  appearances 
some  of  the  products  of  the  disease  now  under  consideration. 

In  the  following  case  the  gradual  diminution  of  the  cervi- 
cal glands  during  the  persistent  use  of  the  hydriodate  adds 
to  its  interest,  whether  the  decrease  resulted  from  the 
remedy  or  not. 

The  patient  was  a  tall,  well  formed  man,  aged  thirty-nine. 
The  obvious  and  striking  feature  of  his  case  was  an  en- 
larged neck,  of  lobulated  outline  and  elastic  to  the  touch; 
the  interval  between  the  lower  jaw  and  collar  bone  of  either 
side  being  distended  almost  to  a  level  with  the  cheek,  while, 
behind,  the  tumor  overlaid  a  part  of  the  trapezius  muscle. 
This  swelling  plainly  consisted  of  enlarged  glands,  varying 
in  size  from  that  of  a  flattened  goose's  egg  downward,  and 


244  LEUCOCYTHiEMIA. 

impacted  together,  yet  elastic  and  without  induration,  desti- 
tute of  heat  or  the  signs  of  acute  inflammation. 

Upon  inquiry,  similar  masses  were  found  to  exist  in  the 
armpits  and  in  the  groins.  In  the  left  armpit  the  largest 
gland  was  about  three  inches  in  diameter,  and  one  lay  behind 
on  the  scapula,  the  whole  being  pressed  out  when  the  arm 
fell.  The  right  armpit  contained  a  somewhat  smaller  mass, 
while  the  larger  glands  of  the  groin  may  have  measured  an 
inch  and  a  half  across.  None  of  these  tumors  were  attended 
with  pain  or  tenderness. 

The  patient  was  at  this  time  (June,  1858)  easily  fatigued, 
but  otherwise  his  health  was  good,  and  he  was  in  active 
business. 

Without  especial  hereditary  tendency,  and  with  previous 
good  health,  he  had  a  bad  cough  through  the  spring  of  1858, 
which  excited  the  serious  anxiety  of  his  friends.  In  May 
he  visited  Sharon  Springs,  a  sulphur  water,  where  he  was 
subjected  to  active  daily  catharsis  during  six  weeks,  his 
strength  not  improving,  though  he  felt  pretty  well.  Imme- 
diately on  his  return  home  in  June  there  was  a  simultaneous 
and  painless  enlargement  of  all  the  glands  abov^  described. 
He  thought  there  had  been,  for  a  month  or  two  before,  a  little 
fulness  of  the  left  side  of  the  neck,  yet  of  this  he  was  not 
certain;  but  the  sudden  growth  of  all  these  masses  was  now 
unequivocal  and  striking. 

He  was  directed  to  take  iodide  of  potassium,  and  in  a 
few  weeks  reached  the  dose  of  fifteen  grains  three  times 
daily,  applying  besides  the  iodide  of  lead  ointment  abun- 
dantly at  night  to  all  the  glands.  This  treatment  was  con- 
tinued through  the  summer  and  autumn,  alternating  occa- 
sionally with  the  experimental  application  of  the  tincture  of 
iodine  to  a  part  of  these  glands.  During  this  time  the  cer- 
vical glands  slowly  and  steadily  decreased  in  size,  becoming 
flabby,  —  the   circumference   of  the   neck   decreasing   from 


LEUCOCYTHiEMIA.  245 

fifteen  and  a  half  to  fourteen  inches,  —  until  the  end  of 
August,  from  which  time  till  the  death  of  the  patient  in 
November  they  rapidly  subsided.  At  the  time  of  death,  the 
glands  on  the  neck  were  quite  flat,  the  largest  measuring 
less  than  an  inch  in  length,  and  the  neck  being  of  normal 
size. 

Equally  remarkable  was  the  subsidence  of  the  swelling  in 
the  left  axilla,  where  a  gland  previously  enlarged  to  the 
size  of  a  hen's  egg  had  now  diminished  to  a  third  of  that 
volume,  others  being  reduced  to  normal  dimensions.  But  in 
the  groins,  the  glands  were  still  swollen  as  before,  while 
the  autopsy  revealed  large  glandular  tumors  existing  in  the 
abdomen. 

During  the  summer  the  patient  became  pale,  and  occasion- 
ally had  epistaxis;  but  until  October  no  other  symptoms  of 
importance  occurred,  except  a  sudden  and  intense  hemi- 
crania  in  the  early  part  of  this  month,  which  yielded  in  three 
or  four  days,  after  the  administration  of  Fowler's  solution. 

In  the  latter  part  of  October,  a  remarkable  vesicular  erup- 
tion appeared  on  both  the  lower  limbs,  occupying  chiefly  the 
thighs,  the  vesicles  presenting  an  inflamed  base,  and  attended 
with  intense  smarting  and  burning.  The  pulse  was  acceler- 
ated to  130  and  upward,  while  the  vesicles  increased  to  large 
phlyctaenas,  until  by  their  coalescence  the  cuticle  was  de- 
tached, so  that  the  front  of  the  thighs  and  the  abdomen 
offered  continuous  raw  surfaces  of  inflamed  granulations  over 
most  of  their  extent,  apparently  occupying  the  substance  of 
the  true  skin,  and  adding  greatly  to  the  suffering  of  the 
patient.  This  circumstance  prevented  examination  of  the 
chest  further  than  to  ascertain  the  probable  existence  of 
pleuritic  effusion,  to  which  attention  had  been  called  by  the 
dyspnoea  which  now  supervened. 

The  patient  was  confined  to  the  house  only  a  fortnight 
before  death,  which   occurred   on   November   11,   1858,   its 


246  LEUCOCYTHiEMIA. 

immediate  cause  being  fever  of  an  irritative  type,  appar- 
ently induced  by  the  spread  of  this  remarkable  herpetic 
eruption,  although  neither  this  nor  the  final  pleurisy  had 
any  obvious  connection  with  the  disease  of  the  glands  and 
of  the  viscera  which  the  autopsy  revealed. 

Autopsy^  hy  Dr.  Ellis. —  Head  not  examined. 

The  left  pleural  cavity  contained,  by  estimate,  nearly  one 
pint  of  serum.  The  pleura  of  the  lower  lobe  of  the  lung  was 
covered  with  a  thin,  recent,  reticulated,  fibrinous  layer. 
In  the  opposite  pleural  cavity  there  was  also  a  small  amount 
of  serum. 

The  great  part  of  the  lower  lobe  of  the  left  lung  was  com- 
pressed, but  a  portion,  upwards  of  two  inches  in  diameter, 
had  a  somewhat  yellowish  appearance,  as  in  the  third  stage 
of  pneumonia,  but  was  limited  in  a  remarkable  manner  by  a 
sharply  defined  line.  A  part  of  the  lower  lobe  of  the  right 
was  also  firm,  and  of  a  dull  red  color,  as  from  compression. 
The  remainder  of  the  lungs  was  healthy. 

The  heart  was  generally  hypertrophied,  but  without  val- 
vular disease  or  other  lesion.  The  right  side  was  filled  by 
a  large  yellowish  white  coagulura,  which  extended  into  the 
vessels  in  different  directions.  In  the  left  ventricle  was  a 
small  amount  of  the  same.  Many  of  the  veins  examined  in 
the  different  parts  of  the  trunk  were  filled  with  similar 
coagula.  These  all  differed  from  the  coagula  usually  seen, 
where  a  separation  of  the  fibrine  has  taken  place.  They  were 
less  gelatinous,  more  opaque,  and  altogether  peculiar,  their 
exact  appearance  not  being  expressible  in  words.  From  the 
jugular  or  subclavian  vein,  however,  there  escaped  a  sub- 
stance resembling  thick  pus. 

The  liver  was  very  large,  weighing,  by  estimate,  about 
seven  pounds.  On  some  parts  of  the  surface  were  depres- 
sions or  cicatrices,  and  portions  had  a  somewhat  lobulated 
appearance,  but  the  latter  was  not  well  marked.     The  sub- 


LEUCOCYT£LEMIA.  247 

stance  generally  was  of  a  brownish  red  color,  very  much  like 
that  of  the  healthy  organ,  but  the  cut  surface  did  not  look 
perfectly  healthy,  although  the  change  was  indescribable.  In 
the  right  lobe,  scattered  over  a  portion  three  or  four  inches 
in  diameter  beneath  the  upper  surface,  was  a  peculiar  whit- 
ish deposit,  looking  somewhat  like  firm  encephaloid,  distrib- 
uted for  the  most  part  in  the  form  of  points  and  streaks,  as 
an  infiltration  among  the  lobules,  the  largest  portion  not 
being  more  than  two  or  three  lines  in  diameter,  but  still 
continuous  with  the  rest. 

The  spleen  was  ten  inches  long,  six  broad,  and  four  thick. 
Its  consistence  was  sufficiently  normal. 

In  each  kidney  were  a  number  of  white  bodies,  about  a  line 
in  diameter,  and  of  the  same  color  and  general  appearance 
as  the  deposit  in  the  liver. 

The  left  supra-renal  capsule  was  quite  large,  and  contained 
much  of  the  same  whitish  substance  described  in  connection 
with  the  liver.  The  right  capsule  was  perhaps  slightly 
affected  in  a  similar  way. 

The  intestines  were  not  opened,  but  externally  appeared 
healthy. 

The  cervical  glands  were  somewhat  enlarged,  but  not  suffi- 
ciently to  produce  any  deformity  of  the  neck. 

Those  of  the  abdomen  generally,  the  lumbar,  the  iliac,  the 
mesenteric,  etc.,  were  very  much  enlarged,  many  of  them 
being  upwards  of  two  inches  in  diameter.  They  were  for 
the  most  part  rather  soft,  friable,  and  of  a  mingled  light  and 
dark  red  color.  Some  contained  small  ecchymoses.  In  one, 
in  the  left  lumbar  region,  suppuration  had  taken  place. 

The  other  organs  appeared  sufficiently  healthy. 

Microscopic  Examination.  —  The  purulent  looking  substance 
from  the  subclavian,  and  the  yellowish  white  coagula,  were 
found  to  be  composed  almost  entirely  of  small  granular 
corpuscles  from  0.004  mm.  to  0.005  mm.  in  diameter,  corre- 


248  LEUCOCYTHiEMIA. 

spending  with  the  (jlohulins  as  described  by  Robin  in  the 
Memoirs  of  the  Biological  Society  of  Paris,  The  globules 
in  the  liquid  blood  from  the  subclavian  were  mostly  red. 

A  few  larger  cells  were  seen,  resembling  the  ordinary  white 
corpuscles  of  the  blood.  Acetic  acid  caused  perhaps  some 
contraction  of  the  smaller  corpuscles,  and  showed  them  to 
be  identical  with  the  nuclei  of  the  larger. 

The  enlarged  glands,  the  spleen,  the  white  substance  in 
the  liver,  and  that  in  the  left  suprarenal  capsule,  contained 
an  abundance  of  small  corpuscles  similar  to  those  found  in 
the  blood.  In  the  spleen  they  were  gathered  together  in 
groups,  while  the  red  disks  floated  singly  through  the  field. 

This  case  is  one  of  great  interest,  being  as  it  were  almost 
an  epitome  of  the  facts  which  have  been  slowly  gathered 
from  isolated  sources  since  the  attention  of  the  profession 
was  first  called  to  the  disease  by  Virchow  and  Bennett. 

We  have  here  combined  the  two  great  varieties,  splenic 
and  lymphatic;  but  not  that  precise  condition  of  the  blood 
which  we  should  expect  were  the  views  of  Virchow  correct. 
Two  kinds  of  white  corpuscles  have  been  described ;  one 
large,  like  the  ordinary  white  corpuscles  of  the  blood;  the 
other  small,  to  which  Robin  has  given  the  name  of  fjlohulins. 
An  excess  of  the  former,  Virchow  declares,  belongs  to  the 
splenic  variety ;  of  the  latter,  to  the  lymphatic.  In  one  case 
the  enlargement  of  the  spleen  and  glands  was  equally  well 
marked,  yet  the  globulins  were  almost  the  only  white  corpus- 
cles seen.  Robin  reports  a  case  in  which  the  spleen  only 
was  affected,  and  yet  the  same  small  corpuscles  predominated 
very  much  over  the  others.  He  also  speaks  of  the  resem- 
blance between  the  small  globules  and  the  nuclei  of  the  large, 
after  the  addition  of  acetic  acid. 

New  formations  like  those  found  in  the  liver  and  supra- 
renal capsule,  although  exceedingly  rare,  have  been  noticed. 


LEUCOCYTH^MIA.  249 

Virchow^  reports  a  case  in  which  white  deposits  were  found 
in  the  pleura,  stomach,  intestines,  and  liver.  These  pre- 
sented the  same  appearances  as  the  enlarged  glands,  and, 
examined  microscopically,  contained  similar  nuclei. 

Virchow^  also  mentions  two  cases  of  the  kind,  in  one  of 
which  the  liver  contained  minute  whitish  deposits  composed 
of  nuclei  like  those  of  the  lymphatic  glands.  In  the  other, 
the  liver  and  kidneys  were  the  seat  of  growths  in  which  were 
corpuscles  resembling  those  found  in  the  blood  of  the  heart. 

This  new  formation  he  regards  as  similar  to  that  which 
occurs  in  the  lymphatic  glands,  not  owing  to  mere  infiltra- 
tion with  blood,  but  to  a  substitution  of  lymphatic  elements. 

But  by  far  the  most  important  feature  in  the  case  is  the 
subsidence  of  the  lymphatic  glands.  So  far  as  has  been 
ascertained,  nothing  of  the  kind  has  been  anywhere  recorded. 

The  connection  between  the  condition  of  the  blood  and  that 
of  the  internal  organs  is  established.  The  question  of  their 
relation  to  each  other  will  naturally  arise.  Virchow  con- 
siders that  the  change  in  the  blood  is  consecutive,  but  it 
must  not  be  supposed  that  it  necessarily  follows  the  enlarge- 
ment of  the  spleen  or  other  organs,  for  such  is  not  the  case. 
Neither  does  an  increase  in  the  number  of  the  white  corpus- 
cles always  indicate  the  existence  of  leucocythsemia.  There 
may  be  an  excess  of  them  after  great  losses  of  blood,  in 
chronic  exhausting  diseases,  or  in  those  which  are  very 
acute,  especially  in  pneumonia.^ 

1  Archiv  fiir  Pathologische  Anatomie,  vol.  xii.  p.  38. 

2  Gesammelte  Abhandlungen,  p.  207. 

3  For  an  article  on  "Leucocythaemia,"  by  Calvin  Ellis,  M.D.,  published 
in  connection  with  the  preceding  paper,  see  the  Boston  Medical  and  Sur- 
gical Journal,  February  9,  1860. 


250  SURGICAL   CASES  AND   COMMENTS. 


SURGICAL   CASES   AND   COMMENTS. ^ 

Case  I.  —  EncJiondromatous  Tumor  of  the  Scapula. 

The  following  case  is  interesting  chiefly  for  the  large  size 
of  the  tumor.  The  patient  is  a  farmer,  residing  in  Salem, 
Conn.,  and  twenty-six  years  of  age.  His  appearance  is 
healthy,  and  his  strength  is  such  that  he  shoulders  his  im- 
mense burden  without  difficulty,  and  walks  about  with  alac- 
rity. He  states  that  six  years  ago  a  tumor  appeared  upon 
the  back  of  the  right  scapula,  and  continued  to  grow  slowly 
for  about  four  years,  when  it  had  attained  the  size  of  an 
orange.  During  the  last  two  years  the  growth  has  been 
much  more  rapid.  It  now  extends  from  a  line  just  outside 
the  vertebral  column  and  parallel  to  it,  over  the  right  shoul- 
der, apparently  involving  about  two  thirds  of  the  clavicle, 
and  the  upper  six  inches  of  the  humerus.  It  is  of  almost 
bony  hardness,  of  very  irregular  outline,  and  firmly  attached 
at  its  base.  The  irregularities  are  discovered  both  in  its 
general  outline,  which  is  elevated,  and  at  certain  parts  which 
are  characterized  by  uniform  conical  elevations,  half  an  inch 
or  more  apart,  and  rising  an  eighth  of  an  inch  or  more  from 
the  surface,  these  last  being  more  numerous  upon  its  outer 
aspect,  and  hard  or  only  slightly  elastic.  Upon  the  outer 
and  upper  surfaces  of  the  tumor  is  a  growth  of  hair,  some 
inches  in  diameter,  upon  a  discolored  skin,  which  without 
doubt  belonged  originally  in  the  axilla,  and  from  which  it 
has  been  displaced  by  the  growth  of  the  tumor.     The  clavicle 

1  From  the  Records  of  the  Boston  Society  for  Medical  Improvement ; 
published  in  the  Boston  Medical  and  Surgical  Journal,  March  31,  1864. 


SURGICAL  CASES  AND  COMMENTS. 


251 


has  become  thickened,  and  is  lost  beneath  the  mass.  The 
humerus  presents  two  distinct  knots,  one  below  the  tumor, 
the  other  upon  its  inner  aspect.  The  skin  is  everywhere 
movable,  excepting  a  small  inflamed  spot  upon  the  outer 
side,  where  it  shows  some  tendency  to  ulceration. 

The  following  measurements  were  taken  at  the  Massachu- 
setts General  Hospital,  December  28,  1863.  Circumference  of 
base  forty-five  inch- 
es ;  antero-posterior 
circumference,  in- 
cluding the  axilla, 
thirty-nine  inches; 
antero-posterior, 
transverse  and  ver- 
tical diameters,  each 
fourteen  inches. 

The  growth  of 
this  tumor,  the  man- 
ner in  which  it  has 
invaded  the  bony 
structures,  its  char- 
acteristic outline,  its 
firmness  and  elasti- 
city, and  the  contin- 
ued good  health  of 
the  patient,  leave  lit- 
tle doubt  of  its  en- 
chondromatous  character. 

A  graphic  representation  of  the  tumor  is  seen  in  the  ac- 
companying wood-cut,  from  a  photograph  taken,  as  the  man 
stood  before  a  mirror,  by  Black,  of  this  city.  This  skilful 
artist  has  furnished  to  the  College  Museum  a  number  of 
large  and  admirable  representations  of  the  patient,  who  was 
exhibited  to  the  medical  class  in  attendance  upon  the  lectures, 


252  SURGICAL  CASES  AND  COMMENTS. 

as  now  to  this  Society ;  the  patient  himself  appreciating  fully 
the  interest  that  has  been  felt  in  his  case,  and  cheerfully  sub- 
mitting to  whatever  it  was  desirable  to  do  for  its  full  examina- 
tion and  for  the  perpetuation  of  its  remarkable  features. 

March  14,  1864,  Dr.  J.  13.  S.  Jackson  recalled  attention  to 
the  above  case,  and  gave  the  following  final  history  of  it. 

During  the  past  week  Dr.  Bigelow  received  notice  of  the 
death  of  this  patient,  and  of  the  willingness  of  his  mother 
that  the  body  should  be  disinterred  for  examination;  but 
as  he  was  obliged  to  leave  the  city  for  a  few  days,  I  offered 
to  attend  to  the  business  for  him.  An  arrangement  was 
made  with  Dr.  Charles  M.  Carleton,  of  Norwich,  Conn.,  who 
had  previously  shown  a  strong  interest  in  the  case,  and  he 
most  liberally  devoted  an  entire  day  to  the  accomplishment 
of  our  object,  the  place  of  burial  being  at  a  considerable 
distance  from  Norwich.  The  body  was  carried,  in  its  cof- 
fin, to  a  shed  adjoining  the  cemetery;  but  it  was  found  im- 
possible to  make  such  an  investigation  of  the  tumor  there 
as  the  importance  of  the  case  demanded,  and  the  entire  mass 
was  accordingly  removed  and  brought  to  Boston  for  a  full 
examination. 

The  weight  of  the  tumor  was  thirty-one  pounds.  In  regard 
to  structure,  it  consisted,  to  a  great  extent,  of  as  pure  an 
enchondroma  as  would  perhaps  ever  be  seen,  and  the  micro- 
scopic accorded  with  the  gross  appearances.  The  lobes  were 
not  so  marked  as  in  the  two  cases  figured  by  Cruveilhier,  ^ 
but  the  lobules  were  well  defined,  and  the  interstices  were 
traversed,  as  usual,  by  an  abundant  fibrous  tissue.  Where 
the  structure  was  firm,  or  rather  dense,  the  lobules  were 
closely  compressed ;  but  in  other  parts,  and  especially  at  the 
lower  part  of  the  tumor,  they  were  considerably  softer,  and 
there  they  hung  more  loosely  together.  To  some  extent 
there  were  no  formed  lobules,  but  the  mass  had  an  amor- 

1  Anatomie  Patliologique,  liv.  xxxiv. 


SURGICAL  CASES  AND  COMMENTS.  253 

phoiis  though  somewhat  granular  appearance;  and  here  it 
was  still  softer,  though  it  had  none  of  the  gelatiniform  con- 
sistence that  enchondroma  sometimes  has.  To  a  small  extent 
the  firmer  portion  of  the  tumor  had  a  rich  reddish  tinge;  but 
there  was  nowhere  any  extravasation  of  blood.  At  some 
depth  from  the  surface,  and  where  the  structure  was  quite 
firm,  there  existed  an  irregular  cavity  that  would  have  held 
two  or  three  ounces ;  it  contained  a  brownish  synovial-like 
fluid,  and  the  defined  parietes  were  formed  by  the  enchon- 
dromatous  structure  itself.  A  smaller  and  similar  cavity 
existed  near  the  above ;  and  in  several  of  the  lobules  there 
was  a  central  softening,  brownish  discoloration,  and  serous 
infiltration,  as  if  in  preparation  for  a  cavity.  The  amount 
of  calcareous  matter  was  quite  large :  and  it  was  generally 
scattered  irregularly  throughout  the  mass  as  a  creamy 
white  amorphous  deposit.  In  very  many  of  the  nodules, 
however,  it  appeared  on  section  as  a  narrow,  defined  line, 
and  in  the  form  of  a  more  or  less  complete  ring;  and  on 
further  examination  this  ring  appeared,  in  some  of  them,  to 
be  a  section  of  a  more  or  less  complete  little  sphere.  After 
removing  typical  specimens  from  different  parts  of  the  tu- 
mor, which  will  presently  be  shown  to  the  Society,  the  re- 
mainder of  the  mass  was  put  into  water,  and  will  be  left  to 
macerate,  when  a  better  idea  will  be  had  of  the  more  solid 
part  of  the  tumor;  the  external  surface  of  the  scapula  being 
apparently  exposed  in  the  course  of  the  dissection  to  the 
extent  of  half  an  inch  or  more. 

The  clavicle  was  perfectly  healthy,  though  surrounded  by 
the  morbid  growth  except  at  its  outer  extremity,  where 
there  arose  from  its  upper  surface  a  bony  tumor  equal  to  one 
and  a  half  inches  in  diameter,  or  more.  This  last  was  of  a 
somewhat  reddish  color  and  cancellated  structure,  and  was 
in  fact  an  exostosis,  as  distinguished  from  the  calcareous 
deposit  above  referred  to;  it  arose  from  the  outer  parietes 


254  SURGICAL  CASES  AND  COMMENTS. 

of  the  bone,  which  last,  though  intimately  connected  with 
it,  was  continuous  and  healthy  in  appearance,  as  appeared 
on  section.  In  this  cancellated  growth  was  one  small 
enchondromatous  deposit,  and  its  upper  extremity  was 
directly  continuous  with  a  large  mass  of  the  same. 

The  shoulder  joint  was  entirely  disorganized.  The  head 
of  the  humerus  was  in  part  covered  by  cartilage ;  but  one  half 
of  it  or  more  was  denuded,  and  to  a  considerable  extent  it 
was  pretty  deeply  carious.  The  deltoid  was  quite  well 
marked,  and  there  were  the  remains  of  some  other  neigh- 
boring muscles ;  but  the  head  of  the  bone  lay  loosely  in  a 
broad  shallow  cavity,  lined  by  a  soft  red  cellular  tissue, 
in  which  no  traces  of  the  original  joint  were  to  be  seen. 
The  humerus  having  been  removed,  the  two  marked  "knots  " 
described  by  Dr.  Bigelow  were  shown,  and  are  distinctly  rep- 
resented in  the  photographs  that  were  exhibited  by  him. 
One  of  them  was  about  as  large  as  the  top  of  the  little 
finger,  acuminated  in  form,  and  on  section  appeared  to  be 
simply  an  outgrowth  of  perfectly  healthy  cancellated  struc- 
ture, the  thin  shell  of  bone  that  surrounds  it,  and  the 
parts  external  to  it,  being  also  perfectly  healthy.  The 
other  was  considerably  larger,  situated  rather  lower  down, 
nnd  about  the  middle  of  the  bone,  but  in  other  respects  sim- 
ilar to  the  one  described,  except  that  instead  of  standing 
directly  out  from  the  bone  it  was  bent  down  upon  it;  and 
on  section  the  cancelli  seemed  to  be  filled  with  an  opaque 
yellowish  white,  cerate-looking  substance ;  it  contained,  how 
ever,  nothing  like  an  enchondromatous  structure.  The  rest 
of  this  bone  was  healthy,  the  reddish  color  of  the  cancellated 
portion  contrasting  strongly  with  the  interior  of  the  "  knot " 
last  described.  The  existence  of  a  pure  exostosis,  apart 
and  by  itself,  in  a  case  of  enchondroma,  is  certainly  an  inter- 
esting pathological  fact  in  relation  to  the  nature  of  this  last 
disease. 


SURGICAL  CASES  AND  COMMENTS.  255 

The  right  subclavian  artery  was  considerably  larger  than 
the  left ;  and,  with  the  nerves,  ran  along  the  surface  of  the 
tumor,  but  without  being  embedded  in  it. 

The  separation  of  the  mass  was  very  readily  effected,  and 
the  parietes  of  the  chest  were  left  in  a  perfectly  healthy 
condition ;  a  very  important  fact  in  reference  to  the  result 
of  the  operation,  if  a  removal  of  the  tumor  had  been  attempted 
during  life. 

The  internal  organs  of  the  thorax  and  abdomen  were  also 
healthy  externally,  with  the  exception  of  a  slight  enlarge- 
ment of  the  vertebral  extremity  of  one  of  the  middle  ribs 
upon  the  right  side,  which  ought  to  have  been  examined,  but 
was  not. 

The  following  history  of  the  patient's  case  was  obtained 
from  his  mother,  who,  though  advanced  in  years,  is  a  woman 
of  intelligence.  It  will  be  observed  that  there  are  dis- 
crepancies when  compared  with  his  own  account,  but  these 
are  probably  no  greater  than  we  should  often  find  in  our 
chronic  cases  if  different  authorities  were  questioned.  The 
tumor  had  been  forming  ten  or  twelve  years ;  but  it  grew 
slowly  until  three  years  ago,  when  it  was  not  larger  than 
the  head  of  a  child  at  birth.  Since  then  its  growth  has 
been  very  rapid,  and  during  the  last  year  it  about  doubled 
its  size.  There  had  been  pain  in  the  "cords  of  the  neck  " 
and  down  the  arm  occasionally  for  years,  and  sometimes  it 
extended  below  the  elbow.  But  the  patient  had  no  pain  in 
the  tumor ;  it  troubled  him  only  by  its  weight.  His  general 
health  had  been  as  good  for  the  last  ten  years  as  for  the  ten 
preceding.  Last  month  he  was  absent  ten  days  on  a  visit  to 
the  medical  schools  of  New  York  and  Philadelphia.  Whilst 
in  the  latter  city  "  the  veins  burst  "  where  the  skin  was 
sound,  but  thin  and  distended  over  the  tumor;  the  bleeding 
was  so  free  as  to  make  him  feel  weak,  but  it  was  arrested. 
He  began  to  fail  from  that  time,  returned  home,  and  died  in 


256  SURGICAL  CASES  AND  COMMENTS.  ; 

eighteen  days.     The  superficial  sores  enlarged  in  size,  hecame    j 
deeper  and  sloughed ;  so  that  after  death  a  cavity  was  found    | 
not  far  from  seven  or  eight  inches  in  diameter  and  one  or    ( 
two  inches  in  depth,   with  much  of  the   calcareous   matter    j 
exposed  upon  the  inner  surface.     The  pain  in  the  arm  in-    ! 
creased,   but  still  there  was   none  in  the  tumor.     He  was 
also  unable  to  move  his  fingers  or  the  forearm,  and  there    | 
was  much  numbness,  though  of  this  last  there  had  been  some 
before.     Meanwhile  he  was  confined  to  his  bed,  with  loss  of 
flesh,  strength,  and  appetite.  ! 

A  very  interesting  fact  that  was  ascertained  by  a  visit  to 
the  mother  of  the  patient  was  the  existence  in  her  own  case 
of  a  well  marked  enchondromatous  tumor.  It  is  situated  just 
above  the  right  knee  joint,  upon  the  outer  aspect  and  towards 
the  front.  It  is  about  half  as  large  again  as  the  fist,  of  a  i 
rounded  form,  quite  knobbed,  dense,  with  a  slight  degree  of 
elasticity,  immovable  upon  the  bone,  and  occasionally  quite 
painful.  She  is  now  sixty-six  years  of  age  and  of  good 
general  health ;  and,  the  tumor  having  existed  from  child-  i 
hood,  she  is  sure,  she  says,  that  it  has  been  as  large  as  it  is 

now  for  forty  years. 

i 

Case  II.  — Fihro-cellular  Tumor  in  Scrotum.  j 

This  case  occurred  in  a  patient  forty-two  years  of  age,  and 
the  disease  was  of  one  year's  duration.  The  general  aspect 
of  the  tumor  was  that  of  a  very  large  hydrocele,  but  further  ' 
examination  showed  the  testicles  to  occupy  nearly  a  normal 
position  high  up  on  each  side  near  the  pubes.  There  was 
no  probability  that  the  tumor  was  of  hernial  origin,  as  the  ' 
inguinal  rings  were  normal  in  size  and  clearly  defined. 
The  tumor  consisted  chiefly  of  slippery  lobes  that  eluded 
the  grasp,  and  was  supposed  before  the  operation  to  be 
either  fatty  or  fibro-cellular.  It  may  be  remarked  that 
behind  and  near  the  anus  the  insertion  of  the  scrotum  had 


SURGICAL  CASES  AND  COMMENTS.  257 

a  brawny  feeling,  and  the  termination  of  the  tumor  was  re- 
marked to  be  there  undefined.  Upon  cutting  down,  the 
first  lobe  that  was  exposed  declared  the  fibro-cellular  char- 
acter of  the  tissue;  and  after  a  dissection,  which  was  ren- 
dered tedious  by  adhesions,  the  tumor  resolved  itself  into  two 
principal  masses.  Each  of  these  was  somewhat  lobulated, 
six  or  more  inches  in  length,  three  or  four  inches  in  diam- 
eter, and  smallest  at  its  neck.  The  dissection  was  carried 
downwards  and  backwards  between  the  bulb  of  the  urethra 
and  the  rectum,  each  of  which  was  exposed,  and  through  the 
triangular  ligament.  The  starting-point  of  these  lobulated 
tumors  was  discovered  to  be  fan-shaped  and  expanded,  high 
up  between  the  prostate  gland  and  the  rectum,  where  liga- 
tures were  passed  around  their  two  pedicles  and  the  masses 
were  cut  away. 

These  tumors  are  interesting  for  their  insertion  deep  in 
the  ischio-rectal  fossa,  which  was  doubtless  their  place  of 
origin.  The  microscope  showed  them  to  consist  of  a  fibroid 
structure,  with  some  attempt  at  an  elongated  cell  growth. 
Lying  free  within  the  skin  and  not  involving  it,  they  differ 
from  a  similar  structure  which  is  occasionally  found  attached 
to  and  corrugating  the  skin  itself.  Examples  of  the  latter 
kind  exist  in  elephantiasis  of  the  scrotum,  and  also  in  some 
other  outgrowths,  of  which  the  following  is  an  example. 

Case  III.  —  Fihro-cellular  Tumor  growing  from  the  Skin. 

The  patient  was  a  young  woman,  twenty-five  years  of  age, 
and  the  tumor  was  of  six  years'  duration  when  it  was  re- 
moved, in  August,  1856.  She  was  troubled  only  by  the 
weight  of  the  mass,  which  was  suspended  from  the  upper 
part  of  the  left  buttock  by  a  large  pedicle,  the  whole  weigh- 
ing after  removal  thirteen  and  one  half  pounds,  and  being 
well  represented  in  the  accompanying  wood-cut.  The  surface 
of  the  tumor  was  discolored,  as  in  elephantiasis,  wrinkled 

17 


258 


SURGICAL  CASES  AND  COMMENTS. 


and  lobulated,  but  perfectly  flaccid.     A  few  days'  confine- 
ment to  the  bed  reduced  the  size  of  the  tumor  and  rendered 

the  whole  mass 
softer,  so  that  it 
was  evident  that 
the  growth  owed 
something  of  its 
size  and  indura- 
tion to  oedema 
from  being  sus- 
pended when  the 
patient  occupied  a 
standing  position. 
The  discolored 
and  lobulated  in- 
vestments of  the 
tumor  terminated 
abruptly  at  their 
margin  in  the 
healthy    skin. 

After    excision 
the  wound  meas- 
ured   about   thir- 
teen by  seventeen   inches,  and  the  patient,   although  much 
prostrated  by  the  operation,  finally  recovered.     Microscopic 
appearances  as  in  the  preceding  case. 

This  winter  (1863-64)  I  again  examined  this  patient,  and 
found  the  tumor  beginning  to  reappear. 


OPERATION  FOR  UNUNITED  FRACTURE.  259 


UNUNITED  FRACTURE  SUCCESSFULLY  TREATED; 
WITH  REMARKS  ON  THE  OPERATION,  i 

The  following  paper  gives  the  details  of  eleven  consecutive 
cases  of  ununited  fracture  successfully  treated,  with  the  ex- 
ception of  one  in  which  the  bone  was  diseased.  Such  con- 
tinued success  justifies  the  belief  that  the  operation  about 
to  be  described  will  effect  the  desired  object  with  more  uni- 
form certainty  than  any  other  method  now  in  use. 

Having  failed  in  a  number  of  cases  to  effect  a  union  of 
imunited  fracture  of  the  humerus,  by  rest,  compression,  blis- 
ters, seton,  drilling,  excision,  dovetailing,  etc.,  and  having 
in  mind  the  experiments  of  Oilier  ^  for  the  production  of 
bone  from  periosteum,  I  determined  when  the  opportunity 
presented  to  avail  myself  of  the  osteoplastic  function  of  this 
membrane.  In  trying  the  experiment  for  the  first  time  (Feb- 
ruary 14,  1860),  I  was  not  aware  that  any  previous  attempt 
had  been  made  to  produce  bony  union  of  ununited  fractures 
by  preserving  the  periosteum  for  that  purpose ;  but  in  the 
ensuing  spring,  at  the  time  of  the  successful  issue  of  the  case 
referred  to,  I  happened  to  meet  with  a  paper  recently  pub- 
lished upon  this  subject,  a  superficial  perusal  of  which 
seemed  to  show  that  its  author  had  covered  the  ground  at 
least  of  novelty  in  the  method.  The  pamphlet  was  mislaid, 
and  I  thought  no  more  of  the  matter,  although  I  had  frequent 
occasions  to  repeat  my  operation,  with  successful  results,  and 
annually  referred  to  the  subject  in  my  lectures  before  the  Med- 

1  Boston  Medical  and  Surgical  Journal,  May  16,  1867. 

2  Gazette  Medicals,  1859,  nos.  xiv.  and  xv. 


260  OPERATION  FOR  UNUNITED  FRACTURE. 

ical  Class  of  Harvard  University.  A  report  of  this  method 
was  also  published  ^  incidentally  in  connection  with  the  testi- 
mony of  the  writer  in  a  suit  for  malpractice,  and  afterwards 
mentioned  in  the  London  Medical  Times  and  Gazette,^  in 
which  I  stated  that  my  own  operation  had  been  anticipated 
abroad.  Within  a  few  weeks  my  attention  was  directed, 
by  my  able  house  surgeon,  Mr.  R.  H.  Derby,  to  the  follow- 
ing paragraph  in  Holmes's  "  System  of  Surgery  " :  — 

"Jordan  ascribes  the  failure  of  resection  to  the  removal 
of  the  periosteum.  He  therefore  by  means  of  some  blunt 
instrument,  as  the  handle  of  a  scalpel,  dissects  this  membrane 
from  the  portions  of  bone  which  he  is  about  to  remove,  and 
leaves  the  two  empty  pouches,  passed  one  within  the  other 
and  in  some  cases  connected  by  suture,  to  form  new  bone. 
The  suggestion  is  undoubtedly  theoretically  sound.  Its 
practical  value,  however,  remains  to  be  proved.  In  two  of 
the  three  cases  which  Jordan  records,  it  failed  of  success ; 
and  he  admits  its  failure  in  the  hands  of  M.  Sedillot. "  ^ 

Upon  again  examining  more  carefully  the  original  paper  of 
Mr.  Jordan,^  I  find  that  his  method  differs  so  essentially 
from  my  own  as  to  explain  both  the  failure  of  two  out  of 
three  cases  cited  by  him,  and  the  almost  uniform  success  of 
the  cases  reported  in  this  paper. 

1.  In  the  method  of  Mr.  Jordan,  no  means  is  taken  to 
secure  the  perfect  and  permanent  coaptation  of  the  bones,  — • 
a  measure  which  underlies  the  favorable  issue  of  the  whole 
proceeding, —  if  we  except  a  suture  of  the  periosteum,  which 
is  wholly  inadequate  to  that  object,  and  which  must  also  give 

1  Boston  Medical  and  Surgical  Journal,  October  15,  1863,  p.  219. 

2  February  6,  1864,  p.  155. 

3  Vol.  i.  p.  804. 

*  Traitement  des  Pseudarthroses  par  I'Autoplastie  Periostique.  Par 
Joseph  Jordan,  F.  R.  C.  S.,  Chirurgien  en  Chef  de  I'Hopital  de  Manchester. 
Paris,  1860. 


OPERATION  FOR   UNUNITED   FRACTURE.  261 

way  in  a  short  time.     This  omission  alone  is  fatal  to  any 
considerable  success  in  the  operation. 

2.  The  muscle  is  detached  from  the  periosteum, ^  and  the 
periosteum  then  pounded  to  detach  it  from  the  bone,  meas- 
ures tending  materially  to  devitalize  the  tissue  upon  which 
success  most  depends. 

3.  Mr.  Jordan  believes  that  suppuration  hinders  bony 
union,  and  therefore  ingeniously  modifies  the  whole  opera- 
tion for  the  purpose  of  preventing  a  suppuration  which  is  in 
reality  inevitable,  and  must  therefore  be  met  and  provided 
for,  controlled  and  directed,  and  which  does  not  impede  the 
desired  result. 

It  may  be  added  that  an  oblique  section  of  the  already 
tapered  bone,  as  recommended  by  him,  and  especially  the 
rabbet,^  is  not  to  be  advised,  as  it  tends  to  impair  the  vital- 
ity of  the  broken  extremities ;  and,  finally,  that  an  apparatus 
of  plaster  is  hardly  sufficient  to  insure  subsequent  immo- 
bility, while  one  of  gutta  percha,  by  confining  transpiration, 
is  irritating  to  the  skin. 

The  chief  cause  of  ununited  fracture  is  undoubtedly  the 
severity  of  the  local  injury,  although  perhaps  the  constitution 
of  the  patient  or  an  obliteration  of  the  osseous  artery  may 
in  a  few  cases  have  to  do  with  it.  It  occurs  in  bones  which 
have  been  run  over,  or  after  accidents  from  machinery  which 
bruise  and  devitalize  the  injured  part.  The  obstinacy  and 
persistence  of  this  lesion  under  treatment  are  well  known, 
and  have  arrested  the  attention  of  surgeons,  who  have 
devised  many  expedients,  though  often  unsuccessfully,  for  its 
relief. 

In  performing  the  operation  which  I  have  found  to  be  so 
efficacious,  the  extremities  of  the  false  joint  are  to  be  attacked 
where  they  approach  nearest  to  the  surface,  unless  vascular 

1  See  Plate  III.  of  Mr.  Jordan's  pamphlet. 

2  An  interlocking,  called  also  in  carpentry  rebate. 


262  OPERATION  FOR  UNUNITED  ERACTURE. 

or  nervous  trunks  are  in  the  way;  in  the  arm,  in  all  the 
cases  I  have  seen,  upon  the  outside;  a  free  incision  being- 
contrived  in  each  case  with  especial  reference  to  the  ready 
exit  of  pus.  The  musculo-spiral  nerve,  which  is  often  dis- 
placed and  tied  down  by  lymph,  is  to  be  carefully  looked  for 
and  avoided,  and  were  it  not  for  the  precaution  here  requi- 
site the  bone  might  be  exposed  by  a  single  incision.  The 
principal  bony  extremities  being  found,  the  interval,  which 
is  sometimes  quite  irregular  and  interlocked,  is  gradually 
divided,  and  the  ends  turned  out,  the  dissection  being  mate- 
rially aided  by  an  assistant,  who  powerfully  flexes  the  false 
joint.  As  it  yields,  care  is  taken  to  prevent  the  muscles  from 
being  stripped  from  the  periosteum,  which  they  adhere  to  and 
aid  in  nourishing.  When  one  extremity  is  fairly  exposed,  a 
crucial  or  other  regular  incision  is  to  be  made  in  the  ragged 
callus  which  overlies  the  periosteum  at  its  tip,  which  should 
be  then  seized  by  strong  toothed  forceps,  and  efforts  made  to 
tear  it  out  of  the  rugous  inequalities  of  the  formerly  inflamed 
bone.  After  a  little  delay  and  dissection,  the  flaps  begin  to 
yield;  with  some  coaxing,  the  terminal  adhesions  are  de- 
tached, and  the  sound  bony  shaft  is  reached,  where  the 
periosteum  is  only  too  easily  stripped  from  the  bone,  re- 
quiring great  care  lest  the  shaft  should  be  denuded  higher 
than  the  intended  section.  The  soft  tissues  being  now 
protected  by  spatulae  or  flexible  strips  of  copper,  the  end  of 
the  shaft  is  removed  by  a  common  saw,  the  length  of  this 
fragment  being  determined  by  the  amount  of  periosteum  it 
has  been  necessary  to  detach.  Half  an  inch  of  good  cylin- 
drical periosteum,  with  as  much  more  of  ragged  tissue  hang- 
ing at  its  extremity,  has  usually  covered  from  three  quarters 
of  an  inch  to  an  inch  and  a  half  of  bone.  Perhaps  half  an 
inch  of  sound  shaft,  including  the  irregular  or  conical  tip, 
which  varies  in  extent,  is  a  good  rule  of  length  for  the  ex- 
cised piece  in  most  cases.     The  other  extremity  is  now  to  be 


OPERATION  FOR  UNUNITED  FRACTURE.  263 

turned  out  and  treated  in  the  same  way,  and  this  terminates 
the  dissection,  leaving  only  the  wire  to  be  inserted.  For 
this  purpose  holes  are  bored  in  each  extremity  with  a  good 
bone-drill,  larger  than  the  wire,  at  a  little  more  than  half 
an  inch  from  the  end,  and  through  one  wall  only.  A  pure 
silver  or  plated  copper  wire  is  inserted  from  without  inward 
in  one  end,  and  inversely  entered  from  within  outward  in  the 
other;  the  size  of  the  wire  ordinarily  used  is  No.  10  of 
Stubbs's  iron  wire  gage.  The  ends  of  the  bone  are  brought 
together  accurately,  and  the  two  ends  of  the  wire  twisted 
until  the  twist  is  long  enough  to  protrude  at  the  external 
wound.  The  incision  is  then  brought  together  by  sutures, 
leaving  an  adequate  exit  for  pus,  and  the  apparatus  is 
applied. 

I  have  found,  on  the  whole,  that  the  best  apparatus  for  the 
humerus,  when  that  bone  has  been  the  seat  of  the  operation, 
consists  of  a  firm  concave  splint  of  iron  and  leather,  made 
to  fit  the  top  and  outside  of  the  shoulder  as  low  as  the  axilla, 
and  thence  horizontally  to  the  neck,  and  secured  by  a  strap 
around  the  opposite  axilla;  a  similar  gutter  to  receive  the 
elbow  and  forearm  flexed  at  a  right  angle;  and  the  two 
united  by  a  narrow  iron  strap  on  the  back  with  another  on 
the  front  of  the  humerus,  adjustable  as  to  its  length.  The 
splint  can  be  thus  shortened  when  in  place,  so  as  to  keep 
the  extremities  of  the  bone  in  contact,  and  is  nearly  immov- 
able in  spite  of  the  great  leverage  of  the  arm  upon  the  wire, 
while  the  dressings  can  be  readily  applied  in  the  open  inter- 
val without  disturbing  the  arrangement. 

For  the  femur,  a  pasteboard  splint  may  be  moulded  to  the 
anterior  aspect  of  the  thigh  and  leg,  and  then  stiffened  with 
dextrine,  an  interval  for  the  wound  being  left.  The  whole 
limb  is  then  secured  to  this  by  bandage,  and,  surmounting 
the  whole,  a  Smith's  anterior  splint  is  applied,  by  which  the 
leg  is  suspended  from  a  railway  on  a  framework  over  the  bed. 


264  OPERATION  rOR  UNUNITED  FRACTURE. 

I  have  usually  employed  water  dressings  at  first,  and  poul- 
tices or  oakum  to  absorb  the  discharge  afterward.  The 
patient  has  remained  in  bed  for  several  weeks,  and  in  fact 
till  some  stiffening  has  taken  place,  after  which  fresh  air 
has  been  enjoined  as  an  invigorating  and  osteoplastic  agent. 
The  diet  has  been  as  generous  as  the  appetite  would  permit, 
and  the  phosphates  have  been  generally  administered  upon 
the  principle  of  giving  egg  shells  to  hens. 

The  wire  has  remained  in  place  until  the  bone  was  firmly 
united,  generally  during  several  months,  and  there  has  been 
in  no  case  evidence  of  any  ill  effects  from  its  presence,  either 
in  producing  necrosis  or  undue  inflammation.  In  fact,  it 
has  in  some  cases  remained  quietly  in  place  after  the  arm 
was  in  use,  and  until  the  patient  returned  for  its  removal. 
In  Case  II.  the  wire  remained  for  two  years. 

To  remove  the  wire,  the  loop  is  best  divided  with  cutting 
pliers,  and  forcibly  drawn  out;  hence  an  advantage  in 
flexible  wire.  This  loop  is  sometimes  quite  superficial, 
but  in  other  cases  is  so  deep  as  to  require  an  incision  to 
reach  it. 

It  may  be  remarked  that  a  partial  stiffening,  dependent  on 
the  inflammation  of  the  soft  parts,  may  take  place  in  a  few 
weeks,  but  the  bone  afterwards  becomes  gradually  loose  if 
the  periosteum  fails  to  do  its  duty. 

The  one  great  point  to  be  observed  in  treatment  is  the 
prevention  of  abscess,  or,  in  other  words,  the  early  and  free 
evacuation  of  imprisoned  pus,  by  large  and  dependent  in- 
cisions, which  here  as  elsewhere  are  incomparably  less  inju- 
rious to  the  tissues  than  the  burrowing  of  pus.  Again,  the 
formation  of  an  abscess  is  always  attended  with  fever,  which 
destroys  appetite  and  weakens  the  patient.  Hence  especial 
vigilance  is  needed  to  detect  any  inflammatory  induration 
supervening  after  suppuration  has  begun,  and  the  first  decided 
pointing  should  be  the  sign  for  an  opening,  to  be  explored  by 


OPERATION  FOR   UNUNITED   FRACTURE.  265 

the  finger,  and  enlarged  inside  or  outside  accordingly.  I 
need  not  say  that  it  is,  in  general,  cruel  to  use  the  knife 
without  an  anaesthetic,  but  here  the  careful  exploration  and 
the  tearing  of  the  adjoining  sinuses  with  the  finger,  if  ade- 
quately done,  absolutely  demand  it,  for  the  comfort  of  both 
surgeon  and  patient.  In  a  long  experience,  I  have  never 
seen  a  patient,  unless  already  moribund,  really  worse  for 
ether,  but  I  have  often  seen  a  weak  person  prostrated  by  the 
excitement  and  suffering  of  an  operation,  when  it  was  with- 
held by  the  timidity  or  haste  of  the  surgeon.  As  for  freezing, 
it  is  sometimes  more  convenient  for  short  and  superficial  in- 
cisions and  in  private  practice,  but  when  the  novelty  of  this 
method  has  passed  by  it  will  yield  to  general  ansesthesia. 

In  operating  upon  the  humerus,  the  musculo-spiral  nerve 
demands  particular  consideration.  Winding  around  the 
outside  of  the  arm  near  the  usual  place  of  incision,  it  is 
sometimes  difficult  to  avoid,  especially  when  displaced  by 
the  deformity  and  tied  into  an  indurated  mass  of  lymph.  I 
have  twice  accidentally  divided  it,  in  spite  of  more  than 
ordinary  care;  once  completely,  and  once  leaving  only  a 
single  fibre  at  one  side.  In  the  first  case,  an  operation  had 
been  undertaken  only  a  month  after  a  previous  one,  while 
the  arm  was  still  inflamed.  It  was  on  that  account  absolutely 
impossible  to  keep  the  wound  dry,  and  during  a  protracted 
dissection  the  knife  was  at  last  used  beneath  the  blood ;  the 
nerve  was  imprisoned  and  concealed  in  a  deep  groove  in  the 
new  bone,  and  was  divided  in  separating  the  bones.  On  this 
ground,  I  should  not  advise  a  second  operation  until  the 
traces  of  active  inflammation  from  the  previous  one  had 
disappeared.  In  this  last  case  the  neurilemma  was  reunited 
by  a  small  suture.  In  both,  the  power  of  the  paralyzed  ex- 
tensors ultimately  returned,  completely  and  unequivocall}-. 
In  a  third  case,  now  under  treatment,  partial  paralysis 
ensued  after  the  operation,  but  the  nerve  had  been  nowhere 


266       OPERATION  FOR  UNUNITED  FRACTURE. 

seen,  and  could  hardly  have  been  divided.  Here,  however, 
the  fragments  were  so  short  that  a  powerful  and  contin- 
ued effort  had  been  required  to  make  their  ends  protrude, 
jamming  the  muscles  in  their  interval,  and  very  likely  thus 
injuring  the  nerve.  The  fingers  are  now  regaining  their 
motion.  In  this  instance,  which  was  a  gun-shot  wound, 
the  operation  failed  twice,  there  being  still  some  necrosis 
about  the  bone,  of  which  the  lower  fragment  was  enlarged 
to  at  least  double  its  normal  diameter.  In  future,  under  sim- 
ilar circumstances,  I  should  consider  the  operation  contra- 
indicated,  unless  there  appeared  to  be  no  good  chance  of 
getting  rid  of  the  necrosis  by  time  or  interference.  Other 
things  being  equal,  it  is  better  to  wait  unnecessarily. 

The  case  most  favorable  for  operation  is  undoubtedly  that 
of  a  healthy  subject,  where  the  bony  extremities  are  of 
natural  size.  In  an  ununited  fracture  of  long  standing, 
atrophy  tapers  the  bones,  and  in  consequence  obliges  more 
extensive  excision. 

The  only  instance  I  have  encountered  of  ultimate  failure 
was  one  of  extreme  softening  of  the  bone  by  interstitial  ab- 
sorption, a  condition  which  was  not  ameliorated  by  invig- 
orating measures,  including  the  free  and  protracted  use  of 
the  phosphates. 

Case  I.  —  Humerus. 

E.  J.,  aged  twenty-two,  entered  the  Hospital  on  October 
14,  1857.  Eleven  months  before,  his  right  arm  was  caught  in 
a  "splitting  machine,"  and  drawn  in  between  the  cylinders. 
A  compound  comminuted  fracture  of  the  radius  and  ulna 
was  produced  at  about  their  middle,  and  a  compound  frac- 
ture of  the  humerus  rather  below  the  middle.  The  fracture 
of  the  humerus  did  not  unite,  that  of  the  forearm  did. 

October  15.  A  seton  was  passed  between  the  fractured 
ends. 


OPERATION  FOR  UNUNITED  FRACTURE.  267 

February  24,  1858.  No  union.  Seton  removed.  Subse- 
quently, emplastrum  cantharidis  was  applied  over  the  frac- 
ture ;  the  ends  of  the  bones  were  rubbed  together. 

May  12.  No  union.  An  ijicision  was  made  over  the 
fracture;  the  two  ends  were  exposed,  and  an  inch  removed 
from  each. 

November  21.     Patient  was  discharged,  not  relieved. 

November  15,  1859.  Patient  returned  to  the  Hospital ; 
the  arm  was  perfectly  useless,  and  occasionally  caused  pain. 
He  was  prepared  for  anything  that  should  offer  a  reason- 
able prospect  of  success,  or  even  for  amputation  as  a  last 
resort. 

December  17.  Patient  etherized,  and,  with  the  view  of 
producing  irritation,  each  fractured  extremity  was  split 
with  a  pair  of  strong  forceps,  made  for  the  purpose  with 
chisel  blades,  which  punctured  the  skin  at  opposite  points, 
and  slowly  penetrated  the  bone,  the  handles  of  the  forceps 
being  compressed  in  a  vise.  A  splint  was  applied,  consist- 
ing of  a  shoulder-cap,  with  a  band  around  the  opposite  side, 
and  a  cap  for  the  elbow  and  forearm.  These  two  caps  were 
made  to  advance  towards  each  other  by  a  screw,  so  as  to 
crowd  the  ends  of  the  bones  together. 

December  18.     Comfortable. 

January  15,  1860.  In  consequence  of  pain  about  the 
shoulder,  the  apparatus  was  removed  and  the  arm  bandaged. 
Little  or  no  union. 

February  14.  Patient  etherized,  and  a  crucial  incision 
made  on  the  external  surface  of  the  arm  over  the  fracture. 
The  band  of  ligamentous  tissue  connecting  the  bones  was 
divided,  and  each  extremity  of  the  humerus  turned  out. 
The  periosteum  was  carefully  detached,  for  an  inch  or  more, 
from  each  end.  The  denuded  ends  were  then  sawed  off. 
A  hole  was  drilled  through  each  bone,  and  a  stout  silver 
wire   passed   through.       The   ends   of  the   wire   were   then 


268       OPERATION  FOR  UNUNITED  FRACTURE. 

twisted,  and  the  extremites  of  the  bone  brought  into  exact 
apposition.  The  external  wound  was  united  with  sutures, 
the  wire  was  left  protruding,  and  the  former  splint  reap- 
j)lied.  After  the  operation,  opiates  were  needed  and  freely 
given. 

21.  Wound  smelling  badly.  A  solution  of  chlorinated 
soda  injected  under  the  apparatus. 

25.     The  apparatus  was  removed,  washed,  and  reapplied. 

March  5.  Wound  closing  by  granulation.  General  con- 
dition good. 

23.     Arm  apparently  stiff. 

29.  To-day  the  arm  and  shoulder  becoming  somewhat 
painful  from  pressure  of  splint  and  necessary  want  of  clean- 
liness, everything  was  removed  with  great  care;  on  slight 
examination  of  the  arm,  no  motion  was  detected.  The  arm 
and  shoulder  were  then  carefully  washed,  lateral  splints 
applied,  and  the  hand  and  elbow  supported  in  a  sling. 

April  4.  The  dressings  were  again  removed.  Slight 
mobility  was  detected  at  the  point  of  fracture.  As  only 
six  weeks  had  elapsed  since  the  operation,  it  appears  to 
have  progressed  as  rapidly  as  any  compound  fracture  of  an 
equally  severe  character  could  be  expected  to  do.  External 
wound  nearly  healed. 

23.   Apparatus  frequently  removed.     Union  firmer. 

June  13.  Union  being  now  very  firm,  and  the  wire  caus- 
ing some  pain,  there  seemed  to  be  no  indication  for  its 
remaining  longer.  He  was  etherized ;  the  wire  was  untwisted 
and  removed. 

July  1.  Arm  was  stiff  and  strong,  with  considerable 
motion  in  the  el):»ow. 

July  12.  At  request,  patient  was  this  day  discharged, 
being  able  to  return  to  his  work,  which  is  that  of  a  leather 
splitter.  The  arm  appeared  to  be  nearly  as  useful  as  the 
other. 


OPERATION  FOR  UNUNITED  FRACTURE.  269 

Case  II.  —  Radius. 

A.  D.,  farmer,  aged  fifty-six.  Four  years  ago,  he  re- 
ceived a  fracture  of  both  bones  of  the  right  forearm,  with 
other  injuries,  by  being  caught  in  machinery.  Splints 
were  applied  and  kept  on  for  nine  weeks,  the  patient  being 
confined  to  bed  on  account  of  necrosis  of  both  tibise  resulting 
from  the  injuries  sustained.  At  the  expiration  of  this  time 
there  was  no  union.  A  starch  bandage  was  applied  and 
allowed  to  remain  for  four  months,  but  still  no  union  was 
secured.  During  all  this  period  his  health  continued  good. 
Nine  months  after  the  receipt  of  the  injury,  an  incision 
was  made  over  the  lower  border  of  the  forearm,  the  ends  of 
the  fractured  bones  were  turned  out  and  sawed  off,  and  the 
extremities  wired  together.  Various  other  measures  were 
subsequently  resorted  to,  but  with  no  success. 

When  admitted  to  the  Hospital,  February  6,  1861,  the 
fractured  ends  of  the  radius  could  be  felt  distinctly;  there 
appeared  to  be  some  ligamentous  union  in  the  ulna.  He 
had  a  very  considerable  use  of  the  hand. 

February  9.  Patient  etherized ;  a  tourniquet  was  applied 
over  the  brachial  artery  to  keep  the  wound  dry.  An  incision 
was  then  made  along  the  upper  border  of  the  radius,  about 
two  inches  in  length.  The  ends  of  the  bone  were  turned  out, 
the  periosteum  was  dissected  up,  and  about  half  an  inch  of 
each  fragment  sawed  off.  A  hole  was  now  drilled  through 
the  upper  wall  into  the  medullary  cavity  of  each  end,  and 
the  ends  of  the  bone  firmly  fastened  together  by  means  of  a 
stout  silver  wire  passing  through  the  holes  and  twisted. 
Two  small  arteries  required  ligature.  The  edges  of  the 
wound  were  drawn  together  by  sutures  and  a  compress  ap- 
plied. The  arm  was  placed  in  an  external  angular  splint, 
and  bandaged  firmly  to  prevent  motion. 

12.     The  pain  in  the  arm  is  quite  severe  and  constant. 


270  OPERATION  FOR  UNUNITED  FRACTURE. 

Considerable  swelling  about  the  wound.  The  bandage  is 
daily  removed. 

March  1.  Wound  nearly  healed  about  the  wire.  Appe- 
tite and  strength  excellent. 

23.  Allowed  to  go  home,  to  return  for  the  removal  of  the 
wire. 

February  13,  1863.  Patient  has  been  able  to  saw  wood 
with  his  right  arm.  He  came  to  have  the  wire  removed, 
which  has  remained  in  place  since  the  operation. 

14.  He  was  etherized.  An  incision  half  an  inch  in 
length  was  made  over  the  point  of  fracture;  the  wire  was 
divided,  and  easily  removed,  two  years  from  the  time  of  its 
insertion. 

Case  III.  —  Humerus. 

J.  C,  laborer,  aged  twenty-four,  entered  the  Hospital  on 
November  4,  1861.  Eight  months  before,  while  turning  the 
crank  of  a  hand-car,  he  became  entangled  in  some  way  and 
his  left  arm  w^as  drawn  under  the  crank  and  fractured  above 
the  elbow.  A  physician  applied  splints  to  the  arm,  and  for 
two  weeks  took  them  off  and  reapplied  them  every  day.  At 
the  end  of  eight  weeks  the  splints  were  finally  removed,  but 
no  union  found  at  the  point  of  fracture.  Four  months  ago 
the  fractured  ends  of  the  bone  were  rubbed  together,  but 
with  no  success. 

Now  the  left  arm  is  about  one  inch  shorter  than  the  right, 
the  ends  of  the  broken  bone  overlapping  each  other.  The 
fracture  extends  from  a  point  about  four  inches  from  the 
lower  end  of  the  humerus,  on  the  outer  side  of  the  shaft  of 
the  bone,  obliquely  inwards  and  downwards,  terminating  at 
a  point  about  two  inches  above  the  internal  condyle.  Crepi- 
tus and  motion  are  very  distinct.  There  has  apparently 
been  no  callus  thrown  out  round  the  fracture.  Motion  in 
the  elbow  joint  is  perfect. 


OPERATION  FOR  UNUNITED  FRACTURE.       271 

November  9.  Patient  was  etherized.  An  incision  three 
and  a  half  inches  in  length  was  made  through  the  skin  over 
the  seat  of  fracture.  The  subjacent  fibres  of  the  triceps 
were  then  divided,  as  was  also,  accidentally,  the  musculo- 
spiral  nerve,  with  the  exception  of  a  single  fasciculus,  by 
which  its  extremities  hung  together  and  which  was  after- 
wards carefully  respected.  The  ends  of  the  fractured  bone 
were  then  turned  out ;  the  periosteum  was  carefully  detached 
from  both ;  a  piece  one  and  a  half  inches  long  was  sawed 
from  the  lower  fragment,  and  a  piece  one  inch  long  from  the 
upper.  A  hole  was  then  drilled  through  each  end  of  the 
fractured  bone,  and  the  two  sawed  surfaces  kept  in  apposition 
by  a  silver  wire  passed  through  the  holes  and  twisted.  An 
inside  and  an  outside  angular  splint,  well  padded,  were  then 
applied.  A  single  suture  was  introduced  to  keep  the  edges 
of  the  wound  slightly  in  apposition.  The  extensors  of  the 
hand  are  paralyzed. 

13.  Splints  were  removed  and  reapplied.  Position 
excellent.     Slight  suppuration  in  wound. 

16.     Splints  removed  and  arm  dressed. 

21.  Slight  paralysis  of  sensation  on  the  posterior  radial 
aspect  of  forearm,  but  no  sensation  over  the  back  of  thumb 
and  radial  side  of  forefinger. 

29.     Appetite  poor.     Pulse  accelerated. 

December  17.     Slight  stiffening  at  point  of  fracture. 

27.  Considerable  stiffness  in  humerus.  Wound  nearly 
closed. 

January  10,  1862.     Union  moderately  firm. 

March  1.  On  careful  examination,  a  slight  yielding  was 
detected  at  the  point  of  fracture. 

11.  A  small  piece  of  necrosed  bone  came  away  from 
wound. 

May  10.  Patient  was  etherized.  An  incision  was  made 
down  upon  the  wire,  which  was  then  extracted. 


272  OPERATION  FOR  UNUNITED  FRACTURE. 

22.     Discharged,  well. 

This  patient  wrote,  April  28,  1867,  that  he  was  a  "  section 
hand  on  the  Northern  Railroad,"  had  not  lost  a  day  since  he 
left  the  Hospital,  and  was  "  well,  doing  the  hardest  kind  of 
work. "     Sensation  and  motion  in  hand  perfect. 

Case  IV.  —  Humerus. 

E.  D.,  laborer,  aged  thirty-one,  entered  the  Hospital  on 
December  4,  1862.  A  year  ago  his  left  arm  was  caught 
by  a  revolving  shaft  and  the  humerus  fractured.  The  skin 
was  much  contused  but  not  perforated.  A  physician  was 
called,  who,  after  examination,  pronounced  the  humerus  com- 
minuted throughout  nearly  its  whole  extent.  He  applied 
splints,  bandages,  etc.,  and  on  the  third  week  reapplied  them, 
at  the  same  time  making  considerable  extension  to  bring 
the  fragments  into  position.  At  the  end  of  the  fourth  week 
he  announced  that  the  union  was  getting  firm,  and  a  week 
later  he  removed  the  splints  and  applied  strips  of  pasteboard. 
A  few  days  after  this,  by  a  sudden  movement,  the  fragments 
were  displaced,  although  very  slightly.  After  two  weeks, 
by  the  statement  of  the  physician,  they  had  become  firmly 
united  again.  In  the  middle  of  May,  he  reported  that, 
although  well  united,  they  were  not  strong,  and  he  applied 
bandages,  etc.,  intimating  that  it  would  be  a  year  before  the 
bones  would  be  firm  enough  to  bear  hard  usage.  Three 
weeks  after  this,  the  patient  had  the  bandages  removed  to 
wash  the  arm,  and  his  wife  at  once  declared  that  the  bones 
were  loose.  Various  measures  were  then  taken  to  procure 
union.  For  the  past  four  months  he  has  not  interfered  with 
the  false  joint,  but  has  given  his  attention  to  recovering  the 
motion  of  the  elbow,  stiffened  by  long  disuse.  The  false 
joint  is  a  little  below  the  middle  of  the  humerus. 

December  6.  Patient  was  etherized.  An  incision,  four 
inches  long,  was  made  over  the  outer  aspect  of  the  false 


OPERATION  FOR  UNUNITED  FRACTURE.  273 

joint,  and  the  ends  of  the  bones  were  exposed.  Both  were 
irregular  in  shape,  especially  that  of  the  upper  fragment. 
They  were  bound  together  by  a  tough  pearl-colored  gristly 
material,  quite  firm  to  the  knife.  The  periosteum  was  dis- 
sected up  and  turned  back  from  about  an  inch  of  each  end ; 
the  bones  were  then  sawed  off  square,  and  a  hole  bored  at 
a  point  a  quarter  of  an  inch  from  the  points  of  section.  The 
two  fragments  were  brought  into  apposition  and  held  in  place 
by  a  silver  wire  passed  through  these  holes  and  twisted. 
The  free  ends  of  the  wire  were  long  enough  to  project  from 
the  wound.  Sutures  were  then  inserted,  and  angular  splints, 
external  and  internal,  were  applied. 

10.  Suppuration  well  established.  Splints  removed,  and 
wound  dressed. 

20.  Has  lost  appetite  during  the  last  twenty-four  hours. 
On  removing  splints,  an  erysipelatous  blush  was  seen  over 
the  whole  upper  arm.  R.  Quiniae  sulphatis,  gr.  ij.,  three 
times  a  day.     Beefsteak  and  wine,  if  he  will  take  them. 

24.     Splints  changed.     Doing  better. 

January  2,  1863.  Patient  is  quite  strong  and  cheerful. 
On  removing  the  splints  to  change  dressings,  considerable 
stiffness  is  found  in  arm.  Suppuration  is  moderate ;  the 
wound  is  closed,  except  immediately  about  the  ends  of  the 
wire. 

4.  Considerable  pain  at  the  point  of  fracture  and  in 
elbow. 

14.     Walks  about. 

16.  The  pus  has  burrowed  towards  the  elbow.  Much 
weaker.     Beefsteak,  wine  and  eggs. 

23.  There  is  tenderness  and  redness  over  the  internal 
condyle,  apparently  from  the  commencement  of  a  large 
abscess. 

27.  Patient  has  been  very  wretched  since  the  last  record, 
from  great  pain  in  the  abscess.     The  splints  were  unbearable, 

18 


274  OPERATION  FOR  UNUNITED  FRACTURE. 

and  were  removed  yesterday.  The  arm  is  laid  on  a  large 
poultice,  with  an  external  straight  splint.  The  abscess  was 
freely  incised  under  ether,  and  the  various  sinuses  were  torn 
into  one. 

31.  Patient  was  etherized,  and  the  wire  cut  and  with- 
drawn. 

February  4,  Patient  is  improving  wonderfully.  He  sits 
up  all  day,  and  walks  about  freely. 

18.     Wound  entirely  closed. 

26.     The  arm  is  quite  stiff  at  the  point  of  fracture. 

March  9.     Discharged,  well. 

Case  V.  —  Femur. 

B.  H.,  teamster,  aged  twenty-seven,  entered  the  Hospital 
on  March  10,  1863.  Five  hours  before  admission  he  was 
run  over  by  a  heavy  team,  the  wheel  passing  over  the  mid- 
dle of  the  left  thigh.  The  whole  of  the  left  thigh  is  greatly 
swollen  and  ecchymosed,  shortened  about  two  and  a  half 
inches.  The  fracture  is  perhaps  comminuted,  and  at  the 
middle  of  the  femur.     Desault's  apparatus  was  applied. 

April  18.  Comfortable  since  the  last  report.  Desault's 
apparatus  was  removed  to-day.  Limb  in  excellent  position. 
There  is  apparently  considerable  callus,  but  the  thigh  appears 
flexible  at  the  point  of  fracture. 

21.  A  starch  bandage,  stiffened  with  pasteboard,  applied 
to  the  limb  from  the  middle  of  the  leg  to  the  upper  third  of 
thigh. 

30.     Sits  up  daily. 

May  4.  Upon  examination  to-day,  it  was  found  that  there 
was  no  union. 

6.  Desault's  apparatus  reapplied. 

7.  Apply  over  fracture  emplastrum  cantharidis  (six  by 
four. ) 

23.     No  union.     Apply  extension  by  weight. 


OPERATION  FOR  UNUNITED  FRACTURE.  275 

August  1.  Starch  bandage  was  applied  over  leg  and 
thigh.      R.   Calcis  phosphatis,  gr.  x.,  three  times  a  day. 

15.  The  starch  bandage  was  removed,  and  extension  by 
weight  reapplied. 

September  2.  After  a  careful  examination,  it  was  decided 
that  there  was  no  union  at  the  point  of  fracture. 

8.  A  starch  bandage  was  again  applied,  and  patient 
allowed  to  sit  up. 

December  5.  No  union.  Patient  etherized,  and  a  seton 
passed  between  the  fractured  ends  of  bone. 

16.  Profuse  discharge  from  lower  wound. 
27.     Seton  removed. 

February  2,  1864.  Discharge  from  wound  diminished. 
Apparently  but  little  stiffness. 

June  4.  Patient  has  continued  in  the  same  condition 
since  the  last  record.  There  is  no  union.  He  was  ether- 
ized, and  the  ends  of  the  fracture  were  drilled  in  several 
different  places. 

18.  There  has  not  been  the  slightest  inflammation  in 
the  thigh  produced  by  the  drilling. 

July  20.  There  has  been  no  change  in  the  thigh  since  the 
last  report.  The  ununited  ends  of  bone  are  surrounded  by 
a  large  amount  of  indurated  tissue,  which  makes  it  very 
difficult  to  get  at  them.  Patient  etherized,  and  the  ends  of 
the  bone  were  again  and  more  thoroughly  drilled.  At  most 
parts  the  bone  was  quite  hard  and  normal,  but  at  one  point 
it  was  soft,  and  the  drill  on  withdrawal  was  followed  by 
quite  a  stream  of  oil  from  the  degenerated  marrow.  The 
limb  was  placed  in  a  straight  splint. 

November  4.     There  is  no  stiffness  at  the  point  of  fracture. 

12.  The  patient  was  etherized.  A  long  semi-circular 
incision  was  made  on  the  outside  and  back  of  the  thigh,  its 
convexity  downwards,  over  the  ends  of  the  bone,  to  favor 
the  discharge  of  pus.     The  muscles  of  the   thigh   were  so 


276  OPERATION  FOR  UNUNITED  FRACTURE. 

indurated  that  the  ends  of  the  bone  were  turned  out  with 
great  difficulty.  They  were  smooth,  rounded,  and  conical. 
The  periosteum  was  turned  back  for  about  one  inch  on  each, 
and  the  bones,  thus  denuded,  cut  off  with  a  chain  saw.  The 
medullary  substance  was  slightly  degenerated  and  fatty.  A 
hole  was  drilled  through  each  extremity  of  the  bone,  and  a 
wire  passed  through  these  holes  and  twisted,  not  tight,  but 
leaving  a  small  space  between  the  ends,  to  allow  of  sufficient 
motion  to  prevent  breaking  the  wire  or  the  bone.  The 
periosteum  was  brought  together  and  the  wound  closed  by 
sutures.  The  limb  was  placed  in  a  Mclntyre's  double- 
inclined  iron  splint,  bent  at  an  angle  of  135°.  The  opera- 
tion occupied  about  two  hours,  during  which  time  the  patient 
was  kept  thoroughly  etherized.     Cold  water  dressing. 

13.  Patient  has  considerable  irritative  fever.  Pulse  132. 
Tongue  thickly  coated.  The  pain  is  relieved  by  acetate  of 
morphia,  one  sixth  of  a  grain,  subcutaneously. 

15.  Much  brighter.     Pulse  100. 

16.  Suppuration  has  commenced. 

23„  The  leg  and  thigh  have  remained  until  to-day  on  the 
Mclntyre  splint,  but  the  suppuration  has  increased  so  much 
that  it  requires  removal  for  daily  dressing.  A  pasteboard 
splint  has  been  moulded  to  the  anterior  and  inner  part  of  the 
thigh  and  stiffened  with  dextrine ;  to  this  the  thigh  and  leg 
are  firmly  bound,  leaving  the  wound  open.  In  addition,  a 
Smith's  anterior  splint  was  applied,  by  which  the  whole  leg 
is  swung  from  a  framework  over  the  bed. 

27.  The  splint  works  admirably.  Less  pain.  The 
wound  looks  well,  and  is  suppurating  freely.  Appetite 
good. 

December  24.  The  bandages  and  splints  were  removed 
and  reapplied.  There  seems  to  be  considerable  stiffening, 
and  the  bones  are  in  good  position. 

January  13,  1865.  No  motion  is  observed  at  the  point  of 
fracture. 


OPERATION   FOR   UNUNITED   FRACTURE.  277 

February  12.  The  limb  is  so  firm  that  it  was  laid  on  a 
pillow,  with  only  pasteboard  splints  applied. 

April  26.  Under  ether,  the  wire  was  cut  down  upon  and 
removed. 

May  17.  Patient  is  up  and  dressed.  Appetite  and  gen- 
eral health  excellent.  He  wears  a  dextrine  bandage  for  the 
support  it  affords  him. 

June  1.  Walks  about  on  crutches.  The  knee  is  quite 
stiff. 

July  1.  Wounds  entirely  healed.  Motion  in  the  knee  is 
returning. 

12.  The  femur  is  perfectly  firm  and  free  from  pain.  Pa- 
tient furnished  with  a  thick-soled  shoe.     Discharged,  well. 

November  10.  Came  to  the  Hospital  to-day.  Is  able  to 
walk  without  the  aid  of  a  cane.  Not  the  least  motion  can 
be  detected  in  the  femur.     The  knee  is  flexible. 

Case  VI.  —  Humerus. 

T.  C,  soldier,  aged  forty-one,  entered  the  Hospital  on 
April  15,  1864.  He  was  wounded  by  a  Minie  ball  in  the 
right  humerus  at  the  first  assault  on  Port  Hudson,  summer 
of  1863.  The  bone  was  broken  at  about  the  junction  of  the 
middle  and  upper  thirds,  and  was  considerably  splintered. 
According  to  patient's  account,  the  surgeon  sawed  off  about 
an  inch  from  each  end,  and  then  approximated  the  bones  by 
means  of  splints,  but  did  not  wire  them.  He  was  put  in  an 
ambulance,  carried  fifteen  miles  over  a  rough  country,  then 
in  a  steamer  for  some  distance,  and  it  was  two  days  before 
he  arrived  at  a  hospital.  The  wound  soon  healed,  but  the 
bones  did  not  unite,  and  have  not  since. 

April  16.  Patient  etherized.  An  incision  was  made  over 
the  point  of  fracture.  The  ununited  ends  were  forcibly 
everted.  The  periosteum  was  carefully  dissected  up  and 
reflected,  and  the  denuded  portions  sawed  off.     A  hole  was 


278       OPERATION  ruR  UNUNITED  FRACTURE. 

drilled  through  each  end  of  the  fragments.  A  wire  was  then 
passed  through  these  holes  and  twisted.  The  periosteum 
was  brought  together,  and  the  wound  closed  by  sutures.  The 
arm  was  placed  in  an  outside  angular  splint. 

20.  The  arm  has  slipped  from  the  splint,  and  is  quite  out 
of  position,  so  that  the  ends  of  the  bones  are  at  a  slight  angle 
with  each  other.  The  angular  splint  was  removed  and  the 
arm  placed  on  a  broad  straight  splint,  with  two  shorter  side 
splints  to  keep  the  fragments  in  place. 

23.  The  wound  is  suppurating  freely,  and  the  arm  is  in 
good  position. 

May  2,  The  wound  has  nearly  healed,  except  at  the 
point  where  the  wires  emerge. 

June  10.  Patient  walks  about  the  yard,  with  the  arm 
firmly  supported.  There  is  considerable  firmness  at  the 
point  of  fracture. 

24.  The  arm  is  stronger.     Discharged. 

September  17.  Patient  returned  to  the  Hospital  to-day 
with  the  arm  so  strong  that  he  can  use  it  for  all  ordinary 
purposes.  The  wire  was  removed,  and  the  humerus  was 
found  to  be  perfectly  firm. 

December  16,  1865.  The  arm  is  perfectly  firm,  and  for 
some  time  he  has  done  a  great  deal  of  heavy  lifting,  such  as 
wheeling  coal,  without  favoring  the  injured  arm  in  the 
least. 

Case  VII.  —  Humerus. 

E.  S.,  female,  aged  forty-five,  entered  the  Hospital  on 
November  10,  1864.  She  had  an  ununited  fracture  of  the 
right  humerus,  the  result  of  a  compound  fracture  received 
a  year  and  a  half  previously.  Seven  months  after  the  acci- 
dent there  was  no  union  at  the  point  of  fracture.  A  seton 
was  passed  between  the  ununited  ends,  and  allowed  to  re- 
main for  a  month.     Notwithstandinor  this  and  other  forms 


OPERATION  FOR  UNUNITED  FRACTURE.  279 

of  treatment,  no  nnion  followed.  On  entrance,  there  was  a 
fracture  of  the  humerus  in  its  lower  third;  the  ends  of  the 
bone  were  drawn  widely  apart  by  the  weight  of  the  forearm, 
unless  held  in  place  by  an  apparatus  which  she  had  worn 
for  the  previous  seven  months.  She  was  a  large,  corpulent 
woman,  with  flabby  tissues. 

November  19.  Patient  etherized.  An  incision  three 
inches  long,  was  made  on  the  outer  and  posterior  aspect  of 
the  arm,  just  above  the  external  condyle.  The  ends  of  the 
fragments  were  then  turned  out,  the  periosteum  was  dissected 
back  for  about  an  inch  and  a  half  on  the  lower  fragment, 
and  two  inches  on  the  upper.  The  denuded  bone  was  then 
sawed  off,  the  upper  fragment  by  a  single  stroke  of  the  saw. 
The  bone  was  much  atrophied,  softened  and  degenerated, 
the  holes  for  the  wire  being  easily  made  with  an  awl, 
and  the  bony  tissue  easily  cut  with  a  knife.  A  wire  was 
then  passed  through  the  outer  sides  of  the  shaft  of  the  bone, 
and  twisted  so  as  to  bring  the  ends  nearly  but  not  quite  in 
apposition,  lest  the  tight  wire  should  break  the  bone.  The 
edges  of  the  wound  were  brought  together  with  sutures,  and 
the  arm  placed  in  an  inside  angular  splint. 

P.  M.  The  arm  is  so  unwieldy  that  it  cannot  be  suflfi- 
ciently  confined  in  the  inside  splint.  It  was  therefore  laid 
on  a  flat  right-angled  splint. 

27.  Pulse  and  appetite  good.  Wound  clean,  and  suppu- 
rating healthily. 

December  30.  R.  Calcis  phosphatis,  gr.  x.,  three  times  a 
day. 

January  7,  1865.  The  wire  has  apparently  torn  out  of  the 
bone.     No  stiffening  at  point  of  fracture. 

March  20.     No  union. 

April  1.  Patient  was  etherized.  An  incision  was  made 
down  upon  the  bone,  and  the  wire  was  removed.  The  ends 
of  the  fragments  were  turned  out  and  found  so  degenerated 


280  OPERATION  FOR  UNUNITED  FRACTURE. 

that  they  could  easily  be  broken  with  the  fingers.  Forearm 
cedematous  and  tender. 

26.  The  arm  was  amputated,  at  the  patient's  desire.  The 
end  of  the  upper  fragment  was  removed. 

May  21.     Stump  has  nearly  healed. 

June  17.     Discharged,  well. 

Case  VIII.  —  Humerus. 

W.  W.,  carpenter,  aged  twenty-eight,  entered  the  Hospital 
on  January  2,  1865.  Left  humerus  fractured  twelve  weeks 
before  entrance,  by  the  falling  of  an  elevator  in  the  Pacific 
Mills.  The  fracture  was  simple,  and  treated  in  the  usual 
way  with  splints,  but  never  had  shown  any  disposition 
to  unite.  On  admission,  an  ununited  fracture  of  the  left 
humerus  was  found  at  a  point  a  little  below  its  middle. 
The  ends  of  the  fragments  were  in  apposition.  Syrup  of 
the  hypophosphites,  3ij.,  three  times  a  day. 

January  7.  Patient  etherized.  A  narrow-bladed  knife 
was  pricked  through  the  integument  and  muscles  to  the  bone, 
at  the  seat  of  fracture.  A  small  drill  was  then  introduced 
through  the  wound,  and  each  end  of  the  bone  was  drilled  in 
three  places.  The  arm  was  placed  between  an  inside  and 
an  outside  angular  splint. 

26.     On  removing  the  splints,  no  union  was  detected. 

February  25.  Patient  was  etherized.  A  straight  incision 
was  made  through  the  integument,  on  the  outside  of  the  arm, 
down  to  the  bone.  The  musculo-spiral  nerve  was  so  drawn 
out  of  place  and  embraced  by  the  bone  that  it  was  acciden- 
tally divided  in  the  blood  which  welled  up  from  the  tissues, 
still  inflamed  from  the  operation  of  six  weeks  before.  The 
periosteum  was  dissected  from  the  ends  of  the  bone,  which 
were  then  everted  and  sawed  off.  A  piece  half  an  inch  long 
was  taken  from  the  upper  fragment,  and  three  quarters  of 
an  inch  from  the  lower.     A  hole  was  then  drilled  through 


OPERATION  FOR  UNUNITED  FRACTURE.       281 

each  bone,  and  a  silver-plated  copper  wire  passed  through 
and  twisted.  A  suture  was  taken  in  the  neurilemma  of 
each  end  of  the  divided  nerve  and  its  extremities  brought 
together.  Several  arteries  were  tied,  the  wound  was  closed 
by  sutures,  and  the  arm  placed  in  an  inside  angular  splint,  to 
which  it  was  first  firmly  bandaged,  and  then  placed  upon  a 
flat  angular  splint  reaching  from  shoulder  to  hand. 

26.  Complains  of  great  numbness  over  the  dorsal  surface 
of  thumb  and  index  finger,  and  has  general  paralysis  of  the 
extensors  of  the  wrist  and  fingers. 

March  3.     Wound  suppurating  healthily. 

8.  Hand  considerably  swollen,  and  elbow  looking  angry 
and  red.  The  wound  is  everywhere  open.  The  suture  applied 
to  the  neurilemma  came  away  to-day.  R.  Pil.  ferri  iodidi, 
gr.  v.,  three  times  a  day. 

16.     Wound  closing. 

31.     Considerable  stiffness  at  point  of  fracture. 

May  6.     Humerus  quite  stiff. 

25.  But  little  discharge  from  sinus  about  wires.  Appe- 
tite and  general  health  excellent. 

June  24.  Under  ether,  the  wire  was  untwisted  and  with- 
drawn. The  humerus  is  perfectly  stiff.  Sensibility  has 
returned  to  the  thumb  and  index  finger,  but  motion  in  all 
the  extensors  of  the  hand  and  wrist  is  absent. 

March  17,  1866.  Patient  reported  at  the  Hospital  to-day. 
He  has  worked  at  his  trade  since  last  August,  without  incon- 
venience. Motion  in  the  extensors  of  hand  and  wrist  has 
returned  perfectly.  The  humerus  is  entirely  firm,  and  free 
from  pain. 

The  union  of  the  musculo-spiral  nerve,  which  was  com 
pletely  divided  and  brought  together  by  suture  of  the  neuri- 
lemma, and  the  restoration  of   its  function,  are  points  of 
great  interest 


282  OrERATION   FOR   UNUNITED   FRACTURE. 

Case  IX. —  Humerus. 

T.  G.,  laborer,  aged  twenty-six,  entered  the  Hospital  on 
June  12,  1865.  A  year  before  entrance  he  was  thrown  from 
a  hand-car,  one  wheel  of  which  passed  over  the  middle  of  the 
right  humerus,  inflicting  a  compound  fracture.  The  arm 
was  placed  in  an  inside  angular  splint,  and  kept  in  position 
for  six  weeks.  The  external  wounds  healed  readily.  At  the 
end  of  this  time,  the  arm  was  again  broken  at  the  original 
point  of  fracture,  and  has  never  united. 

June  21.  An  incision  three  inches  long  was  made  on 
the  outer  aspect  of  the  arm,  over  the  seat  of  fracture.  The 
musculo-spiral  nerve  was  then  sought,  carefully  dissected  in 
its  sheath  from  the  bone,  and  turned  aside.  The  periosteum 
was  stripped  back  from  the  end  of  each  fragment.  A  piece 
half  an  inch  long  from  the  lower,  and  three  quarters  of  an 
inch  from  the  upper  bone,  was  sawed  off.  The  ends  were 
then  drilled  on  the  outer  side,  and  a  silver  wire  passed 
through ;  the  bones  were  placed  in  apposition,  and  the  wire 
twisted  by  four  half-turns.  The  arm  was  placed  in  the  same 
apparatus  as  that  used  in  the  previous  case.  The  edges  of 
the  wound  were  brought  together  by  sutures. 

23.  Apparatus  reapplied.  The  bones  are  in  good  posi- 
tion.    Some  oedema  of  the  arm. 

27.  Suppuration  is  established.  R.  Calcis  phosphatis, 
gr.  X.,  three  times  a  day. 

July  3.  The  arm  is  much  swollen  about  the  wound,  and 
covered  with  an  erysipelatous  .blush.  Patient  complains  of 
some  headache  and  nausea.  R.  Quinise  sulphatis,  gr.  ij,, 
three  times  a  day. 

10.  The  swelling  and  redness  have  disappeared.  No 
union  at  point  of  fracture. 

28.  An  outside  angular  splint  was  applied,  the  arm  sup- 
ported by  a  leather  sling,  and  patient  allowed  to  sit  up. 


OPERATION   FOR   UNUNITED   FRACTURE.  283 

August  7.  AjDparatus  removed  and  reapplied.  There 
is  slight  stiffening  at  point  of  fracture. 

22.     Only  slight  motion  can  be  detected  in  the  humerus. 

September  11.  The  arm  is  stiff,  but  patient  complains 
of  pain  at  the  seat  of  fracture  when  it  is  examined. 

November  4.  All  discharge  and  soreness  having  disap- 
peared, and  the  humerus  being  perfectly  stiff,  a  pair  of 
curved  scissors  was  thrust  down,  the  wire  cut  close  to  the 
bone,  and  easily  withdrawn. 

December  15.     The  humerus  is  firm.     Discharged,  well. 

Case  X.  —  Humerus. 

W.  M.  W.,  carpenter,  aged  thirty-three,  entered  the  Hos- 
pital on  January  26,  1866.  He  was  wounded  with  a  Minie 
ball  at  the  battle  of  Gettysburg,  and  suffered  a  compound 
comminuted  fracture  of  the  right  humerus.  July  5,  the  bone 
was  resected  and  about  three  inches  removed.  The  wound 
healed  in  five  months,  after  exfoliation  of  the  sawn  extrem- 
ities of  the  humerus.  No  attempt  was  made  to  keep  the 
bones  in  apposition,  and  no  union  was  obtained.  He  re- 
sumed duty  and  served  out  his  full  time  with  his  regiment. 
The  wound  has  never  reopened  or  caused  him  any  trouble. 
Now  several  inches  of  the  middle  of  the  right  humerus  are 
gone,  and  the  two  extremities  can  be  felt,  pointed  and 
considerably  absorbed.  The  whole  arm  is  quite  small  from 
disuse.  The  motion  in  the  shoulder  and  elbow  is  perfect, 
but  the  arm  hangs  useless  from  the  loss  of  substance  in  the 
shaft  of  the  humerus. 

January  27.  Patient  was  etherized.  A  longitudinal 
incision  was  made  over  the  ends  of  the  fragments.  The  end 
of  the  lower  fragment  was  then  everted ;  the  periosteum 
was  carefully  detached  for  a  sufficient  distance  and  turned 
back,  and  half  an  inch  was  sawn  off  from  the  end  of  the 
bone,  which  was  firm  and  healthy.     The  upper  fragment  was 


284  OPERATION  FOR  UNUNITED  FRACTURE. 

treated  in  the  same  way,  but  its  end,  three  quarters  of  an 
inch  of  which  was  removed,  was  degenerated  and  quite  soft. 
The  two  ends  were  then  drilled ;  silver  wire  was  inserted 
and  the  bones  approximated,  leaving  a  small  interval  to 
allow  slight  movement.  The  periosteum  was  returned  to 
its  place,  a  few  vessels  were  tied,  and  the  external  wound 
partly  closed  by  sutures.  The  arm  was  placed  in  an  internal 
angular  splint.     Water  dressing. 

30.  The  arm  is  in  excellent  position.  Suppuration  is 
beginning. 

February  21.  A  large  abscess  above  wound  evacuated 
itself  to-day. 

March  11.  Patient  walks  about  every  day.  Apparently 
some  stiffening  at  the  point  of  fracture. 

17.     An  abscess  is  forming  on  the  inner  aspect  of  arm. 

20.     The  abscess  was  opened  and  discharged  freely. 

31.  The  humerus  is  quite  firm.  Patient  discharged  to- 
day to  return  once  a  week. 

April  27.  Scarcely  any  motion  can  be  detected  at  the 
point  of  fracture. 

May  23.  An  incision  was  made  down  upon  the  wire,  which 
was  cut  and  withdrawn.  The  union  of  the  fractured  ends 
is  firm.  The  apparatus  was  removed.  Patient  returned  to 
work. 

Case  XI.  —  Humerus. 

P.  M.,  laborer,  aged  twenty-three,  entered  the  Hospital  on 
January  12,  1867  He  was  wounded  at  the  battle  of  Cedar 
Mountain,  1862,  by  a  musket  ball.  The  left  humerus  was 
shattered  at  a  point  a  little  above  its  middle.  The  small 
pieces  of  bone  were  removed,  the  ends  sawed  off,  and  the 
fragments  approximated.  Six  months  later  there  was  no 
union;  the  ends  were  again  sawed  off  and  the  bones  wired 
together.     At  the  end  of  two  weeks  the  wire  was  removed. 


OPERATION  FOR  UNUNITED  FRACTURE.       285 

In  October,  1864,  a  number  of  pieces  of  necrosed  bone  were 
removed  from  the  seat  of  fracture ;  there  was  no  union.  In 
November,  1865,  he  entered  the  Hospital.  The  left  humerus 
had  a  false  joint  at  its  middle.  There  was  necrosed  bone  in 
the  lower  fragment  at  the  bottom  of  a  couple  of  sinuses.  An 
incision  was  made  over  the  fracture,  the  periosteum  reflected, 
and  the  ends  of  the  bones  were  sawed  off.  In  March,  1866, 
there  was  no  union.  March  31,  the  periosteum  was  again 
detached  from  both  fragments  for  a  sufficient  distance ;  about 
one  and  a  half  inches  were  sawed  off  from  the  lower,  and  one 
inch  from  the  end  of  the  upper  fragment.  The  ends  were 
drilled,  silver  wire  inserted,  and  the  fragments  placed  in 
apposition.  The  periosteum  was  then  replaced  and  its  edges 
were  united  by  sutures.  April  28,  the  arm  had  stiffened  at 
the  point  of  fracture.  June  10,  he  fell  upon  the  arm  and 
broke  it.  July  15,  he  was  discharged  with  an  ununited  frac- 
ture, to  return  when  the  arm  looked  and  felt  better. 

January  12,  1867.  Patient  was  etherized.  An  incision 
three  inches  long  was  made  over  the  outer  aspect  of  arm 
and  carried  carefully  down  to  the  point  of  fracture.  The 
two  ends  were  found  to  be  much  roughened.  Great  diffi- 
culty was  experienced  in  everting  the  ends  of  the  now  short 
fragments,  and  in  detaching  the  periosteum.  The  bone  was 
finally  separated  from  the  periosteum  for  a  sufficient  dis- 
tance, and  one  inch  was  sawed  from  the  upper,  and  three 
quarters  of  an  inch  from  the  lower  fragment.  The  lower 
fragment  was  two  inches  in  diameter;  the  upper  one  was 
of  normal  size,  but  with  fatty  degeneration  of  the  mar- 
row. A  hole  was  drilled  through  the  sides  of  both  frag- 
ments; a  silver  wire  was  inserted;  the  bones  were  placed 
in  apposition,  and  the  wire  twisted.  The  periosteum  was 
replaced,  and  its  edges  were  united  by  sutures.  The  exter- 
nal wound  was  partly  closed  by  sutures.  A  folded  towel 
was  placed  in  the  axilla  to  lift  out  the  short  upper  frag- 


286  OPERATION  FOR  UNUNITED  FRACTURE. 

ment,  and  the  arm  secured  to  the  side,  the  forearm  across 
the  chest. 

13.  There  is  almost  complete  paralysis  of  the  exten- 
sors of  the  fingers  of  the  left  hand.  No  nervous  trunk  was 
known  to  have  been  divided  in  the  operation,  and  the  paraly- 
sis is  perhaps  due  to  a  compression  of  the  nerve  in  very 
forcibly  everting  the  shortened  fragments. 

21.  The  arm  was  placed  in  an  apparatus,  which  consists 
of  a  firm  cap  about  the  shoulder,  secured  by  a  strap  around 
the  chest;  this  is  made  firm  by  two  steel  bridges  to  a  splint 
that  invests  the  forearm  like  a  coat  sleeve. 

27.  The  arm  remains  in  excellent  position.  The  power 
of  extension  is  returning  to  the  fingers. 

February  3.  The  wound  is  contracting  by  healthy  granu- 
lation. 

6.     Slight  stiffening  at  point  of  fracture. 

16.     R.  Calcis  phosphatis,  gr.  x.,  three  times  a  day. 

March  4.     Allowed  to  walk  about. 

April  16.  The  humerus  is  quite  firm  at  the  point  of  frac- 
ture. Patient  flexes  the  forearm  and  raises  the  humerus 
from  the  side  freely. 

22.  Discharged,  probably  well,  although  sufficient  time 
has  not  elapsed  to  determine  the  fact. 

As  will  be  readily  inferred,  this  humerus  was  materially 
shortened  by  these  consecutive  operations,  two  before  enter- 
ing the  Hospital,  and  three  subsequently  by  myself.  In  fact, 
by  measurement  the  arm  was  seven  inches  shorter  than  its 
fellow,  yet  the  biceps  and  triceps  were  fulfilling  their  func- 
tions, and  the  patient  was  regaining  excellent  motion.  There 
can  be  no  comparison  in  the  value  of  an  arm  of  this  sort, 
however  short,  and  an  ununited  humerus.  At  the  first 
operation,  and  during  the  existence  of  undefined  necrosis, 
the  bony  tissue  of  the  lower  fragment  was  of  a  reddish  hue, 
and  of  a  dense,  brittle,  and  amorphous  texture,  such  as  is 


OPERATION  FOR  UNUNITED   FRACTURE.  287 

sometimes  observed  in  the  denuded  walls  of  the  cavities  of 
sequestra  when  chiselled.  At  the  end  of  about  a  year,  at 
the  next  operation,  when  the  probe  no  longer  detected  dead 
bone,  I  was  agreeably  surprised  to  find  that  this  tissue  had 
given  place  to  a  comparatively  healthy  one,  with  cancellated 
interior. 

Conclusions. 

1.  This  operation  is  a  successful  one. 

2.  Though  not  a  trifling  operation,  it  is  not  dangerous. 

3.  In  the  operative  procedure  the  points  deserving  atten- 
tion are :  the  incisions,  which  should  be  arranged  for  the  free 
escape  of  pus ;  the  periosteum,  which  is  not  to  be  detached 
from  the  muscles,  and  which,  after  being  incised,  should  be 
torn  out  from  the  rugous  inequalities  of  the  bony  extremity, 
and  subsequently  connected  by  suture  or  not;  the  excision 
of  at  least  a  quarter  of  an  inch  of  sound  cylindrical  bone 
in  addition  to  the  irregular  and  tapering  end;  the  tvire, 
which  should  not  be  twisted  too  tightly,  lest  it  break  out 
of  the  bone. 

4.  The  wire  may  be  allowed  to  remain  indefinitely,  with- 
out danger  of  necrosis,  and  usually  until  union  has  un- 
equivocally taken  place,  —  a  period  of  from  two  to  six 
months. 

5.  Burrowing  pus  is  to  be  evacuated  when  it  approaches 
the  surface,  in  such  a  way  that  the  wound  will  insure  its  free 
and  permanent  exit. 

6.  The  patient  is  to  be  invigorated  by  such  food  as  he 
bears,  fresh  air,  and  other  stimulus  if  required, 

7.  The  operation  may  be  repeated  if  it  fails,  but  only 
after  several  months'  interval. 


288 


OPERATION  FOR  UNUNITED  FRACTURE. 


RECAPITULATION. 


Case. 

Bone. 

Cause  of  Injury. 

Duration. 

Wire  Re- 
mained. 

Result. 

Remarks. 

1 
2 

Humerus. 
Radius. 

Arm    caught     in  a 
splittiug  machine. 

Arm  caught  in  ma- 
chinery. 

3  years. 

4  years. 

4  mos. 
2  years. 

Well. 
Well. 

Seton ;  blisters ;  rubbing  ends 
of  bone  together  ;  excision 
of  ends  of  fragments.' 

3 

Humerus. 

Arm    caught    in    a 
hand-car  crank. 

8  mos. 

6  mos. 

Well. 

Kubbing  ends  of  bone  to- 
gether.' 

4 

Humerus. 

Arm  caught  by  a  re- 
volving shaft. 

1  year. 

2  mos. 

Well. 

5 

Femur 

Crushed  by  a  heavy 
team. 

20  mos. 

5^  mos. 

Well. 

Blisters ;  seton ;  drilling  ends 
of  fragments  twice.' 

6 

Humerus. 

Gun-shot  TFOund. 

11  mos. 

5  mos. 

Well. 

7 

Humerus. 

Compound  fracture. 

18  mos. 

4^  mos. 

Ampu- 
tation. 

Softening  of  the  bone. 

8 

Humerus. 

Arm  struck  by  a  fall- 
ing elevator. 

5  mos. 

4  mos. 

Well. 

Drilling  ends  of  fragments.' 

9 

Humerus. 

Crushed   by  wheel 
of  hand-car. 

1  year. 

4^  mos. 

Well. 

10 

Humerus. 

Gun-shot  wound. 

5  years. 

Well. 

Excision  of  ends  of  fragments ; 
excision  of  ends  and  wiring 
fragments ;  two  operations 
by  Dr.  Bigelow.' 

11 

Humerus. 

Gun-shot  wound. 

2i  years. 

4  mos. 

Well. 

Excision  of  ends  of  fragments,  i 

1  Previous  operations,  which  had  failed. 


PERIOSTEAL  REPKODUCTION  OF  BONE.  289 


PERIOSTEAL   REPRODUCTION  OF   BONE.i 

I.  —  Of   the  Condyles   of   the   Humerus  after  Excision 
OF  THE  Elbow  Joint. 

Case  I.  — September  14,  1857,  0.  P.  F.,  aged  twenty- 
nine,  married,  clerk.  Is  a  light-haired,  mihealthy-looking 
man.  Family  liable  to  scrofulous  affections.  Five  years 
ago,  while  at  work  hoisting  goods,  he  struck  his  right 
elbow  a  violent  blow,  causing  great  pain.  The  elbow 
swelled,  and  he  was  laid  up  a  fortnight.  Since  that  time, 
whenever  he  struck  this  joint,  it  would  swell  up  in  a  sim- 
ilar manner.  Last  July  a  fistulous  opening  appeared  a 
little  outside  of  the  olecranon,  and  a  week  or  two  later  a 
second  one  broke  out  about  two  inches  below  the  first. 
These  discharge  a  thin,  purulent  fluid.  A  probe  passes 
under  the  skin  from  one  opening  to  the  other.  No  diseased 
bone  is  felt. 

From  this  date  until  March  27,  1858,  the  record  states 
that  various  sinuses  formed  and  were  laid  open. 

March  27.  Etherized.  An  incision  was  made  over  the 
olecranon,  exposing  a  cavity  in  the  bone  with  carious  walls 
the  size  of  an  almond.  The  diseased  parts  were  removed  by 
the  gouge. 

28.     Very  little  pain.     Doing  well. 

April  21.     Abscesses  continue  to  form. 

June  19.  Patient  etherized.  Joint  opened  by  a  semi- 
circular incision,   and  the  ulnar   nerve  sought  and  turned 

1  Boston  Medical  and  Surgical  Journal,  May  30,  1867. 
19 


290  PERIOSTEAL   REPRODUCTION  OF  BONE. 

aside.  The  ends  of  all  the  bones  were  found  to  be  much 
diseased,  and  about  an  inch  of  the  ulna  and  an  inch  of  the 
humerus  were  removed.  The  head  of  the  radius  was  also 
excised.  But  little  blood  was  lost.  No  arteries  tied.  The 
periosteum,  being  firmly  attached  to  the  coral-like  surface 
of  the  bone,  was  torn  out  from  the  inequalities  with  strong 
forceps.  Wound  brought  together  by  sutures.  Flaps  riddled 
by  old  fistulous  openings.  Arm  placed  on  an  angular  splint, 
with  water  dressing.  —  Evening.  Very  little  pain.  Skin 
warm.     Pulse  100.     No  hemorrhage. 

22.  Edge  of  wound  looks  sloughy.  Comfortable.  Stitches 
removed. 

26.  Pulse  good.  General  condition  as  good  as  before 
operation.  Edges  of  wound  have  opened  and  sloughed. 
Sinuses  clean.     No  pain.     Porter. 

August  17.  Wounds  closing  slowly.  Discharge  much 
diminished.     Appetite  good.     Walks  out  every  day. 

22.     Wounds  flabby.     No  dead  bone  felt.     Strap. 

September  5.  General  health  is  very  good.  Ulcers  have 
contracted  somewhat.  Advised  to  go  into  the  country,  and 
is  discharged. 

November  11,  1858.  Since  leaving  the  Hospital  patient 
has  been  in  the  country.  Looks  as  well  as  when  last  seen. 
About  a  month  after  his  discharge,  an  abscess  opened,  two 
inches  below  head  of  radius.  Now  integument  around 
elbow  is  red  and  inflamed.  There  are  five  fistulous  open- 
ings which  connect  with  one  another  and  centre  in  a  cavity 
formed  by  the  removal  of  the  bones.  No  dead  bone  can  be 
felt.  The  discharge  is  very  slight.  No  pain.  Still  keeps 
on  the  angular  splint.  Has  made  up  his  mind  to  have  the 
arm  off,  and  enters  for  the  purpose  of  operation.  House 
diet.     Ale.     Poultice. 

16.  Has  more  or  less  cough.  Cod  liver  oil,  two  drams 
thrice  daily. 


PERIOSTEAL   REPRODUCTION  OF  BONE. 


291 


20.  Patient  was  etherized,  and  the  arm  amputated  just 
above  the  elbow. 

February  28,  1859.     Discharged,  welL 

It  has  lately  been  ascertained  that  this  patient,  who 
manifested  indications  of  tubercular  disease  of  left  lung 
before  his  arm  was  removed,  died  of  phthisis  about  Decem- 
ber 1,  1859,  the  disease  not  having  been  arrested  by  the 
amputation. 


The  interesting  points  in  this  case  of  excision  of  the  elbow 
joint  are :  — 

The  reproduction  of  the  condyles  of  the  humerus  by  the 
periosteum,  which  was  torn  from  the  interstices  of  the  bone 
of  both  the  original  condyles.  The  horns  which  were  repro- 
duced for  the  insertion  of  the  extensor,  supinator,  and 
flexor  muscles  are  conical  processes,  each  somewhat  more 
than  half  an  inch  in  length,  and  regularly  curved  forwards 
and  inwards,   as  seen  in  the   above  wood-cut  made  from  a 


292  PERIOSTEAL  EEPRODUCTION  OF  BONE. 

photograph  of  the  parts  removed.     The  rugous  surface  of  the 
excised  condyles  is  also  well  shown.  ^ 

The  unfavorable  issue  of  this  case  corroborates  what  seems 
to  be  a  fact;  namely,  that  while  the  elbow  is  a  most  favora- 
ble joint  for  excision  in  cases  of  recent  injury  and  in  healthy 
subjects,  yet  when  this  articulation  —  so  near  the  centre  of 
the  circulation,  and  which  is  therefore  well  nourished,  and 
should  be  prompt  to  take  on  reparative  processes  —  becomes 
carious  from  disease,  it  implies  a  general  feebleness  of  con- 
stitution, and  indicates  the  propriety  of  amputation  rather 
than  excision. 

II.  —  Periosteum  of  the  Forehead  Transplanted  in  a 
Rhinoplastic  Operation. 

Case  II.  — December  1,  1866.  A.  B.,  aged  twenty-two. 
This  young  woman,  at  the  age  of  ten  years,  was  attacked 
with  scrofulous  lupus,  which  resulted  in  the  destruction  of 
the  principal  part  of  the  nose,  including  the  bones  and  as 
far  down  as  the  alae.  A  hole  of  the  size  of  a  silver  dime, 
surrounded  with  cicatricial  tissue,  exposes  the  nasal  cavity. 
The  margin  of  the  alae  remains  half  an  inch  wide  and  re- 
tracted into  the  cavity  of  the  nose,  especially  upon  the  right 
side. 

15.  The  alse  were  dissected  from  their  adhesions  within 
the  nasal  cavity,  and,  being  cut  square,  left  a  margin  a  quar- 
ter of  an  inch  in  width.  A  flap  was  taken  from  the  fore- 
head, in  the  usual  way,  and  brought  into  place  so  as  to  form 
a  nose  and  unite  at  its  lower  margin  with  that  of  the  alae 
and  septum.  In  dissecting  up  the  flap,  the  periosteum  to 
which  it  was  attached  was  carefully  removed  from  the  skull, 
in  the  hope  that  it  would  form  a  new  bridge. 

16.  Wound  looking  well. 

1  For  a  somewhat  similar  specimen,  from  the  practice  of  Prolessor 
Syme  of  Edinburgh,  the  reader  is  referred  to  the  Lancet,  March  3,  1855. 


PERIOSTEAL  REPRODUCTION  OF  BONE.  293 

19.     Every  other  suture  removed. 

25.  It  is  now  evident  tliat  the  exposed  bone  is  becoming 
necrosed. 

March  2,  1867.  The  margins  of  the  wound  upon  the  fore- 
head have  shown  little  tendency  to  approximate  over  the 
exposed  surface  of  bone,  the  whole  of  which  is  dead,  and  is 
becoming  gradually  elastic  and  detached  from  the  subjacent 
tissue.  To-day  (eleven  weeks  after  the  operation)  forceps 
were  introduced  at  the  edge  of  the  wound,  and  the  entire  bony 
surface  lifted  off  in  two  fragments,  being  itself  a  scale  of 
almost  papery  thinness,  and  uncovering  a  healthy  granu- 
lating base. 

31.  Patient  was  etherized,  the  pedicle  divided,  and  the 
eyebrow  restored  to  its  normal  position. 

April  30.     Wound  of  the  forehead  completely  healed. 

May  15.     No  bone  can  be  detected  in  the  new  nose. 

Having,  in  four  preceding  instances,  had  occasion  to  make 
an  entire  new  nose  from  the  forehead,  and  having  been  on  the 
whole  dissatisfied,  owing  to  the  tendency  of  the  new  nose  to 
flatten,  with  the  want  of  resemblance  in  the  result  of  my 
own  efforts  to  the  model  nose  usually  depicted  in  standard 
works  on  surgery  as  the  result  of  the  rhinoplastic  operation, 
I  determined  in  this  instance  to  invoke  the  aid  of  the  peri- 
osteum in  the  formation  of  a  new  bridge.  This  had  already 
been  done  abroad ;  with  what  result,  I  have  been  unable  to 
learn.  I  had,  however,  been  previously  deterred  from  the 
experiment,  in  apprehension  of  the  very  injury  to  the  bone 
which  has  been  mentioned  as  having  occurred  in  the  present 
case.  The  necrosis  of  the  whole  surface  of  the  exposed 
bone,  in  connection  with  the  entire  absence  of  osseous  forma- 
tion in  the  new  nose  five  months  after  the  operation,  is 
not  favorable,  so  far  as  the  evidence  of  a  single  case  may  be 
relied  on,  to  a  repetition  of  this  experiment. 


294  FRACTURES  AND  DISLOCATIONS 


FRACTURES  AND    DISLOCATIONS   OP   THE 
ELBOW  JOINT.i 

There  is  no  class  of  injuries  so  frequently  productive  of 
discontent,  and  perhaps  so  often  the  cause  of  litigation,  as 
the  traumatic  lesions  of  the  elbow  joint.  The  fractures  of 
the  elbow  are  especially  common  in  children ;  and  the  sur- 
geon is  often  called  upon,  some  six  or  eight  weeks  after  the 
accident,  to  say  whether  the  elbow  has  been  properly  set. 
Although  he  should  uniformly  refrain  from  expressing  an 
opinion  which  cannot  be  given  without  a  full  knowledge  of 
the  circumstances  under  which  the  patient  was  treated,  and 
although  it  is  at  that  interval  of  time  occasionally  impossi- 
ble to  say  exactly  what  the  original  injury  was,  yet  he  is 
often  led  to  the  painful  conviction  that  the  result  might 
have  been  better  if  certain  simple  rules  of  treatment  had 
been  rigidly  adhered  to.  These  rules  are  often  lost  sight 
of;  they  do  not  receive  that  prominence  in  books  which  the 
importance  of  the  subject  demands.  It  is  also  a  fact  that  a 
fracture  of  the  elbow  joint,  especially  in  a  young  person, 
may  pass  for  a  sprain,  because  it  fails  to  exhibit  any  marked 
signs  upon  a  casual  inspection,  —  because  the  pain  may  be 
slight  and  the  swelling  such  as  to  mask,  in  some  measure, 
the  character  of  the  injury.  The  medical  attendant,  after 
examining  the  arm,  has  perhaps  enjoined  great  care,  ban- 
daged a  compress  upon  the  parts  with  cooling  applications 

'-  An  Abstract  of  a  Clinical  Lecture,  March  2, 1868,  entitled  "Practical 
Views  of  the  Treatment  of  Fractures  and  Dislocations  of  the  Elbow  Joint, 
and  on  the  General  Impropriety  of  Passive  Motion. '  Boston  Medical 
and  Surgical  Journal,  May  7,  1868. 


OF   THE   ELBOW  JOINT.  295 

or  liniments,  and,  visiting  it  daily,  has  been  surprised  at  the 
end  of  four  or  five  weeks,  when  the  swelling  has  subsided, 
to  find  an  unusual  stiffness  of  the  joint,  —  in  fact,  an  impos- 
sibility of  flexion  or  extension,  —  and,  what  is  of  more  im- 
portance, a  hard  prominence  in  the  bend  of  the  elbow, 
suggestive  of  serious  displacement.  Such  is  the  history  of 
frequently  recurring  cases  of  injury  to  the  elbow  joint, 
resulting,  not  from  a  want  of  ostensible  care  or  solicitude 
on  the  part  of  the  attendant,  but  of  an  omission  of  one  simple 
expedient  in  treatment,  presently  to  be  mentioned,  and  for 
the  want  of  which  deformity  is  imminent ;  although  I  incline 
to  the  belief  that  in  a  majority  even  of  these  cases  a  toler- 
ably good  joint  is  established  in  a  young  person  after  a  lapse 
of  yearSo  I  am  speaking  of  the  simple  and  not  the  compound 
fractures  or  dislocations  of  this  joint,  which  are  very  serious 
injuries.  Cases  may  also  happen  where  the  elbow  is  so 
excessively  swollen  before  the  surgeon  is  called  that  it  may 
be  proper  to  wait  for  the  swelling  to  subside  before  applying 
the  necessary  apparatus ;  but  even  here  the  inflammation 
subsides  more  readily  if  the  elbow  can  be  properly  set,  and 
the  very  large  majority  of  cases  are  not  of  this  character. 

The  rule  I  would  enjoin  upon  you  is  the  following.  As- 
certain if  the  olecranon  is  broken,  which  can  be  done  with 
comparative  ease,  as  it  lies  near  the  surface.  This  injury 
requires  a  special  treatment  In  all  the  other  injuries  of 
the  elbow  joint,  whether  you  are  able  to  make  an  exact 
diagnosis  or  are  wholly  unable  to  do  so  on  account  of  the 
swelling,  treat  them  as  though  the  forearm  had  been  dislocated 
hacktvard,  and  secure  the  arm  at  about  a  right  angle  to  an 
inside  angidar  splint.  The  propriety  of  this  measure  will 
not  be  doubted  with  regard  to  the  more  common  dislocations 
of  the  arm.  The  very  rare  instances  of  the  radius  dislo- 
cated forward,  or  the  all  but  impossible  forward  dislocation 
of  the  ulna  alone,  would  doubtless  declare  themselves,  and 


296  FRACTUllES  AND  DISLOCATIONS 

the  bones  would  be  replaced  during  the  manipulation. 
Practically  speaking,  they  are  so  rare  that  they  need  not  be 
taken  into  account.  But  among  the  fractures,  the  transverse 
fracture  of  the  lower  end  of  the  humerus,  the  T  fracture  into 
the  joint,  the  fracture  of  the  inner  or  outer  condyle  sepa- 
rately, the  comparatively  rare  fracture  of  the  coronoid  process 
of  the  ulna,  or  of  the  radius  or  ulna  near  the  joint,  are  all 
properly  treated  by  the  expedient  above  described;  while 
the  common  injuries  of  the  lower  end  of  the  humerus,  in- 
cluding the  fracture  of  the  internal  condyle  into  the  joint, 
peremptorily  demand  it.  In  these  cases,  it  is  sometimes 
difficult  or  impossible  to  make  an  accurate  diagnosis ;  but 
the  above  treatment  covers  the  whole  of  them,  and  does  harm 
to  none,  while  it  is  the  omission  of  it,  as  I  believe,  that 
directly  leads  to  subsequent  deformity  in  a  large  proportion 
of  them. 

In  a  case  of  this  sort,  my  advice  is  as  follows.  Always 
use  ether,  and  avoid  any  painful  examination  whatever  until 
the  patient  is  fully  under  its  influence.  In  providing  the 
anaesthetic,  I  provide  also  an  internal  angular  splint,  know- 
ing that  the  chances  are  ten  to  one  that  it  will  be  required. 
After  etherization,  the  character  of  the  injury  is  determined 
as  far  as  may  be  without  unnecessary  harm  from  manipula- 
tion of  the  parts,  and,  the  elbow  being  placed  at  right  angles, 
the  wrist  is  drawn  forward,  while  the  humerus  is  pushed 
backward  at  the  elbow,  precisely  as  if  a  backward  dislocation 
were  being  reduced.  In  this  position  it  is  forcibly  maintained 
while  the  fragments  are  adjusted  as  accurately  as  possible, 
and  an  internal  rectangular  splint,  padded  by  a  folded  towel, 
is  applied  by  an  assistant.  To  this  the  arm  and  forearm  are 
now  secured,  the  friction  of  the  bandage  of  the  forearm  being 
relied  on  to  prevent  any  backward  displacement  of  the  latter 
at  the  elbow.  I  need  not  say  that  a  bandage  is  never  to  be 
applied  before  putting  on  the  splint.     An  outside  splint  may 


OF   THE   ELBOW  JOINT.  297 

« 

also  be  secured  to  the  forearm,  if  thought  necessary.  A  few 
inches  of  the  arm  above  and  below  the  elbow  may  be  left 
uncovered  for  cooling  lotions  and  especially  leeches,  if  the 
swelling  or  superficial  congestion  make  them  advisable. 

If  the  olecranon  alone  be  fractured,  a  more  or  less  straight 
position  is  usually  advised.  Do  not  suppose  that,  because 
the  olecranon  is  fractured,  it  is  drawn  up  the  arm  by  the 
triceps  muscle,  as  indicated  in  the  plates.  On  the  contrary, 
it  is  generally  retained  pretty  nearly  in  its  place  by  the 
lateral  ligaments.  A  member  of  the  class  once  asked  me, 
"What  if  the  olecranon  and  internal  condyle  be  both  frac- 
tured? "  In  reply,  I  should  say,  wait  until  it  occurs.  A 
semiflexed  position  might  then  be  a  compromise  between  a 
widened  interspace  at  the  olecranon  and  the  far  more  serious 
deformity  resulting  from  a  displacement  of  the  fragments  of 
the  humerus  for  the  want  of  rectangular  flexion.  But  in  in- 
venting an  injury  of  such  possible  occurrence,  do  not  lose 
sight,  in  the  very  frequently  recurring  fracture  of  the  con- 
dyles of  the  humerus,  of  the  absolute  importance  of  drawing 
the  arm  forward  at  right  angles,  and  confining  it  in  this 
position  by  an  internal  angular  splint.  It  is  the  tendency 
to  backward  displacement  of  the  forearm  that  commonly 
leads  to  deformity  in  these  cases. 

Now  let  us  suppose  that  a  fracture  of  the  elbow  joint  has 
been  overlooked,  and  the  arm  placed  in  a  sling,  as  previously 
described ;  or  that  a  simple  bandage  has  been  applied  to  it, 
perhaps  with  leeches  and  cooling  applications,  and  that 
everything  but  the  proper  thing  has  been  done;  or,  indeed, 
that  the  injury  has  been  so  severe  as  necessarily  to  entail  a 
very  limited  motion  of  the  joint  at  the  expiration  of  perhaps 
four  to  six  weeks.  Consult  the  books  upon  the  subject,  and 
you  will  there  find  that  it  is  necessary,  after  this  interval,  to 
commence  what  is  called  passive  motion,  which  is  generally 
of  a  pretty  active  character.     I  hold  this  teaching  to  be  radi- 


298  FRACTURES  AND  DISLOCATIONS 

cally  wrong;  and  that  such  passive  motion,  as  a  rule,  besides 
occasioning  the  patient  excessive  pain  during  the  operation, 
or,  if  done  with  etlier,  a  good  deal  of  discomfort  afterwards,  is 
productive  of  more  harm  than  good.  It  begets  active  inflam- 
mation, and  is  a  serious  injury  to  a  part  which  is  under 
repair,  and  which  nature  in  its  own  good  time  will  restore 
better  without  than  with.  More  than  this,  I  believe  that 
the  time  lost  by  the  necessity  of  rest  during  these  inflam- 
matory attacks  counterbalances  any  time  supposed  to  be 
gained  by  pumping  the  joint,  lacerating  the  bands  of  recent 
lymph,  compelling  the  stiffened  ligaments  to  bend,  and 
otherwise  doing  violence  to  the  still  inflamed  and  tender 
tissues.  I  speak  now  of  the  pain  and  inflammation  liable  to 
be  awakened ;  but  there  are  other  injuries  which  may  occa- 
sionally happen  in  passive  motion  of  the  elbow  joint.  Among 
them,  the  most  frequent  is  the  separation  of  the  olecranon, 
especially  when  that  was  a  part  of  the  original  injury.  On 
this  account,  I  have  sometimes  been  careful,  when  passive 
motion  seemed  to  be  called  for,  rather  to  extend  than  to  flex 
the  limb,  or  at  any  rate  to  flex  with  great  caution.  The 
fragments  of  the  humerus,  when  they  have  not  been  properly 
replaced,  not  only  occasion  a  stiffness  which  has  been  con- 
sidered especially  to  demand  passive  flexion,  but  unfortu- 
nately become  too  solidly  united  in  their  new  position  to 
allow  of  their  displacement,  or  of  material  benefit  to  the 
arm  by  this  violence  to  the  joint.  If,  when  the  splint  has 
been  removed  at  the  proper  interval  for  repair  (from  four  to 
six  weeks),  the  arm  can  be  flexed  or  extended  through  even  a 
very  small  arc,  not  with  that  deceptive  springiness  due  to 
the  elasticity  of  the  ligaments,  but  in  a  way  to  satisfy  the 
surgeon  that  the  cartilages  are  sliding  one  upon  the  other, 
however  little,  my  rule  is  to  leave  the  rest  to  nature,  with  en- 
tire confidence  in  the  result ;  allowing  the  patient  to  take  off 
his  splint  daily  and  as  he  pleases,  to  flex  and  extend  the  arm 


OF  THE   ELBOW  JOINT.  299 

as  the  pain  and  tenderness  may  allow  him,  encouraging  him 
in  his  attempts  to  reach  his  forehead  with  his  hand.  I  have 
also  often  advised  a  patient  to  bore  holes  in  a  soft  board 
with  a  small  gimlet,  to  increase  the  power  of  rotation.  But 
if  the  cartilages  do  not  slide  through  even  a  small  arc,  and 
motion  is  restricted,  elastic,  and  springy  owing  to  bony  de- 
formity, so  much  the  worse  for  the  patient,  and  so  much  the 
more  remote  and  less  perfect  the  recovery.  I  do  not  believe 
you  can  accelerate  it  by  passive  motion,  as  the  term  is  usually 
understood ;  you  give  the  patient  a  good  deal  of  suffering 
and  the  joint  a  good  deal  of  inflammation.  If  these  views  of 
passive  motion  are  correct,  the  teaching  of  the  books  should 
be  received  with  considerable  qualification. 

The  exception  noted  above,  in  which  passive  motion  is 
undoubtedly  advantageous,  is  when  the  bones  are  in  place, 
the  articular  surfaces  in  shape,  and  the  arm  stiff  from  being 
too  long  kept  in  splints ;  but  this  is  only  likely  to  occur 
after  an  interval  of  months,  just  as  the  arms  of  Indian  fakirs 
are  said  to  become  anchylosed  by  being  maintained  for  years 
in  one  position.  I  had  a  lady  brought  to  me,  who,  having 
lost  sight  of  her  medical  attendant,  and  feeling  her  elbow 
a  little  sensitive  after  a  fracture,  had  kept  a  splint  on  for 
more  than  three  months.  The  elbow  was  of  normal  shape, 
with  little  or  no  tenderness,  but  was  stiff,  and  there  was 
virtually  a  false  anchylosis.  When  the  muscles  were  re- 
laxed by  ether,  a  little  motion  was  discoverable,  as  is  usual 
in  cases  of  false  anchylosis;  and,  with  the  application  of 
moderate  force,  the  bones  of  the  forearm  were  made  to  sweep 
around  the  articular  surface  of  the  humerus,  as  in  a  healthy 
joint.  This  sliding  of  a  healthy  cartilage  contrasts  strongly 
with  the  unyielding  springiness  and  elasticity  where  bony 
deformity  exists.  It  characterizes  the  case  which  passive 
motion  benefits,  where  all  motion  has  been  accidentally 
prevented  for  months,  and  where  there  is  no  deformity  of 


300  FRACTURES  AND  DISLOCATIONS. 

the  articular  surfaces.  Exactly  how  far  these  observations 
on  passive  motion  apply  to  the  knee  and  other  joints  and 
injuries,  I  will  not  attempt  now  to  define,  but  can  only  say 
that  I  have  seen  more  harm  than  good  arise  from  forcible 
flexion  of  the  knee  after  rheumatism  and  after  fracture  of 
the  shaft  of  the  femur. 

In  simple  fractures  of  the  elbow,  except  of  the  olecra- 
non, my  remarks  may  be  summed  up  as  follows.  Always 
etherize  the  patient,  go  through  the  motions  of  reducing  a 
backward  dislocation  of  the  forearm,  and  apply  an  internal 
angular  splint.  When  there  is  bony  deformity  or  project- 
ing callus,  passive  motion  does  harm;  when  the  bones  are 
in  place  and  under  supervision,  it  is  unnecessary. 


CLEFT  PALATE.  301 


CLEFT   PALATE.1 

In  exhibiting  a  plaster  cast  of  a  cleft  palate  recently  oper- 
ated upon,  I  would  direct  attention  to  a  mechanical  expedient 
for  aiding  union  of  the  palate  in  the  operation  of  staphylor- 
rhaphy, first  employed,  so  far  as  I  know,  in  this  case.  Be- 
fore doing  this,  it  may  be  well  briefly  to  review  the  deformity 
and  the  operation  for  its  relief. 

The  cleft  may  be  median  or  lateral.  It  is  either  a  contin- 
uation of  a  hare  lip,  or  exists  independently.  In  the  latter 
case  it  may  involve  both  the  hard  and  soft  palate ;  or  only 
the  soft  palate  may  be  affected,  and,  in  cases  very  favorable 
for  operation,  to  an  inconsiderable  degree.  The  result  of 
this  deformity  is  chiefly  noticed  in  the  nasal  intonation  of 
the  voice,  to  correct  which  various  expedients  have  been 
proposed.  The  name  of  the  late  Dr.  J.  Mason  Warren  is 
associated  in  this  community  with  many  of  our  earlier  oper- 
ations, and  I  think  that  to  him  is  fairly  due  the  original 
suggestion  of  freely  liberating  the  soft  palate  by  dissecting 
it  from  its  upper  attachments  before  drawing  together  the 
margins  thus  liberated.  This  is  perhaps  the  great  improve- 
ment of  the  modern  operation. 

I  am  not  aware  that  Dr.  Warren  described  the  anatomy 
of  the  parts  thus  detached.  This  was  afterwards  done  by 
Mr.  (now  Sir  William)  Fergusson,  who,  having  examined 
the  cleft  palate  of  a  dead  child,  demonstrated  that  the 
malformation  involved  a  contraction  of  the  levatores  palati, 

1  A  Clinical  Lecture,  delivered  on  December  21, 1868.  Boston  Medical 
and  Surgical  Journal,  February  4,  1869. 


302  CLEFT  PALxiTE. 

and  sometimes  of  other  muscles.  I  do  not  know  that  this 
distinguished  surgeon  detached  the  flaps  in  a  way  which 
practically  differed  from  that  repeatedly  accomplished  by 
Dr.  Warren,  but,  having  described  anatomically  the  parts 
thus  dissected,  his  name  is  associated  with  this  feature  of 
the  modern  operation.  The  late  Dr.  Warren  was  impressed 
with  the  belief  that  a  large  majority,  if  not  all,  of  the 
subjects  of  this  operation  were  materially  improved,  if  not 
cured,  of  their  nasal  voice.  A  case  of  my  own,  fifteen  or 
more  years  ago,  led  me  to  scrutinize  this  point  more  nar- 
rowly, and  I  was  led  to  the  conviction  that,  although  a 
patient  occasionally  shows  a  remarkable  improvement  in 
speech,  the  rule  is  the  other  way.  Neither  can  improve- 
ment be  always  expected  at  once,  but  only  after  a  lapse 
of  sufficient  time  to  allow  the  parts  to  become  flexible. 
The  case  I  have  just  mentioned  was  that  of  a  young  lady, 
in  whom  the  nasal  intonation  was  very  marked,  and  in 
whom  the  only  apparent  deformity  of  the  palate  was  a  par- 
tial cleft  of  the  uvula  alone.  The  palate  was  ample,  and 
to  appearance  well  under  muscular  control,  and  yet  this 
congenital  deformity  of  a  bifid  uvula  was  associated  with 
an  imperfection  in  the  mechanism  of  articulation,  which 
months  of  effort  on  her  part,  even  after  the  fissure  was 
closed  by  operation,  failed  to  overcome.  This  case  estab- 
lished the  fact  that  something  is  wanting  for  perfect  articu- 
lation beyond  a  palate  of  normal  size  and  appearance ;  and 
that  although  the  lateral  flaps  of  a  cleft  in  the  soft  palate 
maybe  attached  to  each  other,  often  with  a  result  beautiful  in 
appearance,  it  does  not  therefore  follow  that  the  nervous  and 
muscular  action  will  be  perfectly  restored.  In  the  case  of  a 
wide  fissure  extending  well  forward  through  the  bone,  the 
soft  parts  are  actually  insufficient  to  restore  the  palate,  and 
then  the  usual  result  of  the  common  operation  is  a  band  of 
greater  or  less  width  tightly  stretched  by  cicatricial  contrac- 


CLEFT  PALATE.  303 

tion  across  the  palate,  bounded  behind  by  a  naso-pharyngeal 
chasm  which  it  is  insufficient  to  close,  and  in  front  by  a 
fissure  in  the  bone  which  still  remains.  It  is  difficult  to  say 
that  the  phonation  of  such  patients  is  not  improved  a  little; 
they  are,  indeed,  generally  inclined  to  flatter  themselves 
with  this  belief  after  an  obturator  has  been  adjusted  to  the 
bony  opening.  A  patient  with  palatine  fissure,  in  articulat- 
ing the  words  had  man  says  man  man,  vainly  trying  by  facial 
distortion  to  occlude  the  anterior  narcs ;  while  a  patient  with 
nares  occluded  by  a  tumor,  or  a  cold  in  the  head,  says  had 
had,  or  heautiful  hood,  as  in  the  familiar  poetry  of  "Punch." 
Between  the  nasals  m,  n,  and  ng,  on  the  one  hand,  and  the 
labials  i),  h,  the  Unguals  t,  d,  and  the  gutturals  (improperly 
so  called)  k  and  ^  hard,  on  the  other,  prt)nounced  with 
occluded  nares,  there  is  a  wide  difference;  and  perfect  ar- 
ticulation requires  the  machinery  for  enunciating  at  will 
both  sets  of  consonants.  This  the  healthy  palate  supplies  in 
opening  and  hermetically  closing  the  posterior  nares.  Yet 
there  are  persons  with  sound  palates  who  habitually  talk 
through  the  nose,  as  the  conventional  Yankee  is  said  to  do. 
Such  persons  do  not  make  efficient  use  of  their  levatores 
palati  and  superior  constrictors  of  the  pharnyx.  While  w6 
may  hope  to  approximate  our  patients  to  the  normal  condi- 
tion of  such  persons,  it  should  be  remembered  that  a  very 
small  communication  with  the  nasal  fossae  may  materially 
modify  the  intonation.  The  nasal  quack  to  the  duck,  for 
example,  is  produced  by  the  reverberation  of  a  comparatively 
small  elastic  cavity;  and  a  hole  in  the  human  palate  a 
quarter  of  an  inch  or  even  less  in  diameter  may  produce  the 
same  result.  It  cannot  be  denied,  however,  that  a  very 
marked  improvement  now  and  then  results  from  this  opera- 
tion, especially  in  a  favorable  case ;  and  in  view  of  this  possi- 
bility it  is  certain  that  patients  will  continue  to  demand 
it  at  the  hands  of  the  surgeon. 


30-1  CLEFT   PALATE. 

The  expedient  to  facilitate  union  of  which  I  have  spoken 
consists  in  the  employment  of  a  temporary  artificial  palate, 
in  this  instance  of  hard  rubber,  to  protect  the  parts  during 
cicatrization.  Its  use  was  suggested  to  me  by  Dr.  Beach  as 
a  means  of  shielding  the  tongue  from  metallic  sutures,  and 
thereby  enabling  the  surgeon  to  employ  them  conveniently 
in  this  operation.  It  also  occurred  to  me  that  this  arrange- 
ment would  protect  the  palate  from  the  peristaltic  action  of 
the  tongue  in  swallowing,  and  other  involuntary  movements 
which  endanger  union.  It  is  pretty  well  established  that 
the  success  of  the  modern  operation  for  vesico-vaginal  fistula 
mainly  depends  upon  the  use  of  metallic  sutures,  planted 
near  together  so  as  to  insure  close  contact  of  the  wound, 
which  cause  an  irritation  so  inconsiderable  that  they  can  be 
left  in  place  from  one  to  two  weeks.  Similar  advantage 
ought  to  accrue  from  their  use  in  the  palate.  The  hard  rub- 
ber palate  here  shown  was  made  by  Dr.  Sheppard,  Adjunct 
Professor  in  the  Dental  School  of  this  University,  and  fitted 
so  as  to  cover  the  whole  region  occupied  by  the  palate  after 
the  operation.  It  conforms  with  the  arch  of  the  normal 
palate,  leaving  an  interval  of  about  a  quarter  of  an  inch  be- 
tween it  and  the  mucous  membrane.  Behind,  it  bends  down 
just  far  enough  not  to  incommode  the  tongue,  while  in  front 
it  was  keyed  in  the  interstice  of  the  incisors  left  by  the 
former  hare  lip,  and  laterally  attached  by  silk  threads  to  a 
tooth  on  each  side.  The  whole  is  made  as  accurately  as  if  it 
were  a  plate  for  false  teeth.  A  hole  near  the  front  admits 
the  nose  of  a  small  syringe,  by  which  the  interval  between 
the  plate  and  palate  was  syringed  with  warm  water  twice 
daily.  In  this  case  I  cannot  doubt  that  the  contrivance  was 
of  service.  The  fissure  was  wide,  reaching  to  the  incisors. 
The  flaps  were  detached  well  forward  from  the  bone,  and 
seven  fine  silver  stitches  were  insertedo  The  plate  was  not 
removed  for  the  examination  of  the  parts  until  the  eighth 


CLEFT   TALATE.  305 

day,  when  every  stitch  was  found  in  place  and  was  removed, 
the  union  being  perfect.  During  the  succeeding  week  the 
contracting  cicatrices  at  the  margin  of  the  wide  fissure  of 
the  bony  palate  drew  apart  a  quarter  of  an  inch  of  the  ante- 
rior extremity  of  the  wound,  which  is  less  than  usual  in 
these  cases.  The  width  of  the  remaining  band  was  about 
one  inch  and  a  quarter,  wdiich,  considering  the  size  of  the 
palate,  is  more  than  we  could  have  expected.  I  cannot  but 
think  that,  whatever  the  operation  upon  the  palate,  a  more 
perfect  union  will  be  secured  by  silver  sutures  thus  protected 
than  by  the  ordinary  method. 

It  remains  to  notice  some  of  the  expedients  which  have 
been  of  late  years  adopted  in  connection  with  this  operation. 
One  of  the  most  valuable  of  these  is  the  so  called  "  gag  "  of 
Mr.  T.  Smith,  of  London,  a  steei  instrument  by  which  the 
jaws  are  effectively  kept  open,  and  the  tongue  at  the  same 
time  depressed,  so  that  the  parts  are  fully  exposed,  and  the 
operation  can  be  performed  with  great  facility  under  ether, 
even  in  young  subjects.  This  one  has  been  fully  tested  in 
the  operations  of  staphylorrhaphy,  excision  of  tonsils,  etc., 
with  ether,  during  the  past  few  months,  at  the  Massachusetts 
General  Hospital,  and  the  operation  above  described  was 
performed  with  its  assistance. 

Much  attention  has  been  directed  to  the  different  methods 
of  closing  the  openings  behind  and  in  front  of  the  transverse 
band  of  varying  width  which  results  from  the  union  of  the 
soft  palate  in  large  fissures.  This  has  been  usually  effected 
by  an  obturator.  I  have  not  met  with  as  good  results  as 
many  writers  declare  they  have  obtained,  by  an  operation 
which  consists  in  simply  detaching  the  soft  tissue  from 
the  bony  margins  of  the  anterior  fissure.  Of  this  tissue 
Langenbeck  says  that  it  is  "  more  fragile  and  more  adherent 
to  the  periosteum  as  we  approach  the  gums ;  in  fact,  you 
can  only  borrow  autoplastic  flaps  with  a  chance  of  success 

20 


306  CLEFT  PALATE. 

from  the  posterior  part  of  the  mucous  membrane,  the  thick- 
est and  least  adherent,  especially  that  which  covers  the 
horizontal  plates  of  the  palatine  bones. "  But  there  can  be 
little  doubt  that  by  detaching  this  flap  we  secure  a  union  of 
the  soft  palate  to  a  point  a  little  farther  forward  than  might 
otherwise  be  possible,  and  so  facilitate  the  subsequent  use 
of  an  obturator.  A  later  operation,  usually  attributed  to 
Langenbeck,  is  said  to  be  much  more  effectual  in  closing 
the  anterior  fissure.  It  consists  in  denuding  the  whole 
horizontal  bony  palate,  and  uniting  upon  the  median  line 
the  soft  tissue  thus  detached.  A  good  idea  of  this  method 
may  be  obtained  by  supposing  two  large  lateral  flaps  to  be 
thus  formed  from  the  whole  soft  and  hard  palate  combined. 
The  tissue  is  best  detached  from  the  bony  palate  by  square 
or  spade-pointed  blades  inclined  to  their  handles,  by  which 
the  membrane  is  cleanly  dug  or  hoed  from  the  bone.  After 
starting  it,  blunt  instruments  work  best.  Such  flaps  are 
still  insufficient  anteriorly,  and  a  lateral  incision  is  there- 
fore made  on  each  side,  close  to  the  alveolar  processes,  from 
the  second  incisor  nearly  to  the  last  molar.  These  incisions 
stop  in  front  at  the  incisors,  and  behind  near  the  hamular 
processes,  in  both  cases  before  reaching  the  bony  canals  of 
the  arteries.  Thus  the  arteries  of  the  flaps  are  preserved, 
before  and  behind,  and  the  flaps  are  wholly  detached  from 
the  horizontal  bone,  except  at  three  points,  the  anterior  at- 
tachment being  a  pedicle.  The  lateral  incisions  are  usu- 
ally made  first,  and  the  process  of  detaching  the  soft  parts 
is  there  begun  and  continued  inward  toward  the  median 
line.  When  the  fissure  is  wide,  and  one  or  both  sides  of  the 
bony  palate  nearly  vertical,  the  lateral  incision  may  not  be 
needed.  The  anterior  fissure  thus  occluded  by  obturator  or 
membrane  can  have  no  immediate  influence  in  bad  cases 
upon  the  pharyngeal  opening,  although  it  is  quite  probable 
that  after  a  lapse  of  time  the  elastic  membrane  will  insure 


CLEFT  PALATE.  307 

a  more  flexible  soft  palate  and  a  better  phonation  than  an 
unyielding  obturator. 

M.  Passavant,  of  Frankfort,  in  a  paper  on  the  means  of 
obviating  the  nasal  intonation  in  congenital  fissures  of  the 
bony  and  membranous  palate,  etc.,^  after  speaking  of  the 
inefficiency  of  present  operations  in  attaining  this  result  in  a 
majority  of  instances,  cites  a  case  of  much  improvement 
after  an  operation  in  which  the  posterior  border  of  the  soft 
l)alate  was  attached  to  the  pharynx  behind  it,  the  surfaces 
being  first  denuded  and  then  placed  firmly  in  contact  by 
means  of  sutures.  This  result,  however,  was  only  attained 
at  the  expense  of  a  transverse  incision  of  the  soft  palate, 
by  the  gaping  of  which  the  palate  was  brought  into  contact 
with  the  pharynx.  I  ought  here  to  add  that,  within  a  few 
months,  I  have  attempted  this  operation  in  one  instance 
without  liberating  the  soft  palate  by  a  transverse  incision, 
and  that  in  this  case  the  pharyngeal  border  failed  to  unite. 
But  it  seems  not  improbable  that  these  and  other  com- 
paratively recent  investigations  will  lead  to  some  operation 
to  be  performed  under  ether,  (with  the  invaluable  aid  of 
the  "gag"  above  mentioned,)  which  may  so  far  occlude  the 
nasal  cavity,  or  shut  it  off  from  that  of  the  mouth  by  a  flexi- 
l)le  septum,  as  to  insure  in  bad  cases  an  improvement  of 
the  voice,  which  now  only  happens  occasionally.  It  is 
l)robable  that  the  combined  hard  and  soft  rubber  palate, 
alleged  to  afford  relief  in  these  cases  without  an  operation, 
would  be  even  more  efficient  as  the  results  of  surgical  inter- 
ference become  more  complete. 

It  remains  only  to  describe  the  common  operation.  If 
ether  is  not  to  be  used,  the  patient  should  educate  the  soft 
palate  to  insensibility  for  a  few  days  by  frequently  tickling- 
it  with  a  feather.  The  liest  way  to  hold  the  soft  palate  for 
dissection  is  with  double  hooks  terminating  in  firm  single 
1  Archives  Generales  de  Medecine,  1865. 


308  CLEFT  PALATE. 

points,  meeting  and  crossing  a  little.  A  single  puncture  is 
thus  made.  Common  forceps  slip,  and  tear  and  bruise 
the  parts.  I  divide  the  muscles  until  the  flaps  are  free, 
using  scissors  doubly  curved  on  the  edge  and  flat,  one  for 
each  side,  passing  the  finger  occasionally  behind  the  flap 
to  find  where  it  is  most  tense  and  unyielding.  The  edges  are 
now  to  be  pared;  this  incision  bleeds  least,  and  is  therefore 
perhaps  best  done  first.  The  whole  thickness  of  the  edges 
of  the  palate  should  be  included,  and  if  there  be  doubt 
upon  this  point,  owing  to  the  discoloration  of  the  parts,  the 
detached  sliver  may  be  floated  in  water  to  see  if  it  is  of  uni- 
form width.  Further  dissection  may  be  made  before  or  be- 
hind at  discretion,  and  the  parts  brought  together  by  common 
small  curved  needles  threaded  with  silk  or  wire ;  then  each 
suture,  to  facilitate  finding  it  again,  has  its  ends  united,  and 
each  is  drawn  in  succession  through  the  fissures  of  a  plate 
of  cork,  cut  like  a  comb  and  held  on  the  forehead  of  the 
patient.  The  needle-holder  should  not  have  jaws  more  than 
a  quarter  of  an  inch  wide,  —  otherwise  they  will  straighten 
a  curved  needle,  —  and  not  extending  more  than  half  an 
inch  beyond  the  pivot,  so  that  the  long  handles  may  se- 
cure a  firm  grip.  The  best  needles  are  the  smaller  sizes 
of  glovers'  needle,  curved  with  different  bends,  the  temper 
being  then  partially  restored,  and  their  shanks  flattened  by 
grinding  or  honing,  to  prevent  them  from  turning  in  the 
forceps.  The  silk  sutures  are  tied  with  common  knots ; 
or  the  wires  with  a  half  knot  and  then  a  twist,  and  are 
to  be  left  in  place  until  union  is  perfect,  or  as  long  as  they 
are  of  any  service. 


CLEFT  PALATE. 


309 


PRACTICE   IN  PRONUNCIATION. 

Chart  to  be  used  by  Patients  after  an  Operation  for 
Cleft  Palate. 

The  great  difficulty  iu  pronouncing  correctly  with  a  cleft  palate 
is  to  distinguish  the  nasals  from  the  mutes,  thus :  i^  and  h  from  in, 
pap  or  bab  from  mam;  t  and  d  from  n,  tat  from  nan;  h  and  g 
(hard)  from  ng. 

"Tar"  is  well  pronounced  by  most  beginners  with  an  obturator. 
When  the  beginner  can  pronounce  "stark"  and  "car,"  he  has  the 
key  to  most  of  what  here  follows.  These  words  should  be  practised 
carefully;  not  "start"  and  "tar,"  but  "stark"  and  "car";  and 
should  be  spoken  loudly,  or,  as  the  elecutionists  say,  "exploded." 


1.    tar  artar  kar  arkar 

ark,  ache ;  take,  steak ;  took,  cook ;  talk,  cork ; 


2.  kar 

3.  kar 

4.  kar 

5.  kar 

6.  kar 

7.  kar 

8.  kar 


arkar 
arkar 
arkar 
arkar 
arkar 
arkar 
arkar 


arkgar 

arktar 

arkdar 

arkpar 

arkbar 

arklar 

arksar 


kgar 
ktar 
kdar 
kpar 
kbar 
klar 
ksar 


kar 
caught. 

gar 
tar 
dar 
par 
bar 
lar 
sar 


Practise  all  the  above  with  the  following  vowels :  — 


9.    0  as  in  coke. 
Thus,  instead  of  kar,  akar,  etc.,  ko  —  oko  —  oklo 
10.   a  (long)  as  in  cake. 
IL    i  as  in  kite. 
12.   e  as  in  keep. 


klo  —  lo. 


13. 

u  as 

in  suit. 

14. 

kar 

arkar 

arngar 

arkar 

arngar 

kar 

ngar 

15. 

tar 

artar 

arnar 

artar 

arnar 

tar 

nar 

16. 

par 

arpar 

armar 

arpar 

armar 

par 
bar 
dar 
sar 

mar 
mar 
mar 
rar 

Practise  reading  loudly  from  a  book. 


310  TURBINATED  CORPORA  CAVERNOSA. 


TURBINATED    CORPORA    CAVERNOSA.^ 

That  the  turbinated  bones  are  embedded  in  erectile  corpora 
cavernosa  is  a  fact  of  interest  to  both  surgeon  and  physician. 
But  that  this  simple  and  satisfactory  explanation  of  the 
every-day  phenomena  of  a  "  cold  in  the  head  "  has  not  yet 
passed  into  current  science  is  sufficiently  shown  by  the 
little  attention  given  to  the  subject  in  most  standard  modern 
works  of  descriptive  anatomy.  Venous  congestion,  dilated 
veins,  veins  resembling  sinuses,  venous  plexuses,  etc.,  are 
sometimes  briefly  spoken  of  as  explaining  the  singular  tume- 
faction of  the  Schneiderian  membrane  during  inflammation ; 
but  very  commonly  this  membrane,  as  a  locality  of  erectile 
tissue  of  any  sort,  is  ignored  altogether. ^ 

1  Boston  Medical  and  Surgical  Journal,  April  29,  1875. 

2  It  is  a  little  curious  that  Rouget,  who  has  made  an  elaborate  study 
of  erectile  organs  makes  no  mention  of  the  Schneiderian  mucous  mem- 
brane. (Du  Tissu  erectile,  etc.,  Paris,  18.56;  Journal  de  la  Physiologie 
de  Brown-Sequard,  vol.  i.,  18.58 ;  Comptes  Rendus  de  la  Societe  de  Biologie, 
18.57 ;  Des  Mouvements  erectiles.  Archives  de  Physiologie  Normale  et 
Pathologique,  1868,  p.  671.) 

Eugene  Boeckel,  in  the  Xouveau  Dictionnaire  de  Medecine  et  de  Chi- 
rurgie  Pratique,  Paris,  1870,  torn.  xiii.  pp.  721,  722,  in  an  extended  con- 
sideration of  the  subject,  states,  as  the  result  of  his  own  investigations 
and  those  of  Kobelt,  that  erectile  tissue  is  confined  to  the  genital  appara- 
tus, male  and  female,  internal  and  external ;  but  that  Rouget,  who  "  con- 
siders as  erectile  every  organ  in  which  arterial  or  venous  plexuses  are 
submitted  to  the  action  of  smooth  muscular  fibre,  .  .  .  finds  erectile 
tissue  "  not  only  "  in  the  wall  of  the  vagina,  the  uterus,  the  substance 
of  the  broad  ligaments,  and  in  the  wing  (aileron)  of  the  ovary,"  but 
also  "in  the  iris."  The  Schneiderian  membrane  is  omitted  in  this 
enumeration. 


TURBINATED  CORPORA  CAVERNOSA.  3.11 

Many  years  ago,  while  examining  for  operation  the  cleft 
palate  of  a  patient  who  happened  to  have  a  catarrh,  I  was 
attracted  by  the  excessive  turgescence  of  the  mucous  mem- 
brane on  and  about  the  inferior  turbinated  bone;  but  yet 
more,  when  it  suddenly  collapsed  like  the  lung  of  a  small 
animal.  Remarking  then  to  an  assistant  that  this  phenom- 
enon was  much  more  suggestive  of  the  action  of  erectile 
tissue  than  of  merely  vascular  congestion,  I  have  since  not 
unfrequently  ventured  to  tell  some  suffering  doctor  that  he 
would  find  upon  the  inferior  turbinated  bone  an  erectile  tissue 
to  elucidate,  if  it  did  not  alleviate,  his  symptoms.  Having, 
during  the  last  year,  examined  the  tissue  in  question  my- 
self, I  am  able  to  identify  a  remarkable  and  well  formed 
cavernous  structure,  at  least  upon  the  inferior  and  middle 
turbinated  bones. 

The  difference  in  the  size  of  the  distended  and  collapsed 
cavernous  bodies  is  quite  striking,  and  is  best  seen  upon  the 


Fig.  1.1 

inferior  turbinated  bone.  Collapsed,  the  outline  and  dimen- 
sions are  nearly  those  of  its  attenuated  bony  framework. 
Distended,   it   becomes  an   angry,  turgid   mass,    of   uneven 

1  Upper  jaw  showing  sections  of  turbinated  corpora  cavernosa,  inflated 
and  dried. 


312 


TURBINATED   CORPORA   CAVERNOSA. 


surface  and  livid  color,  completely  closing  the  lower  nostril. 
A  pouch-like  process  projects  from  the  rear  of  the  bone, 
increasing  its  length,  and  with  the  aid  of  a  Itlowpipe  readily 
showing  to  the  naked  eye,  on  section,  the  cavernous  cells. 
It  is  this  reticulated  pouch  that  is  seen  with  the  mirror  at 
the  back  of  the  nares.^  Above  it  is  seen  the  middle  turbi- 
nated mass,  similarly  distended;  and  if  the  injection  of  the 
whole  membrane  is  considerable,  the  nasal  septum  also 
swells  to  the  thickness  of   nearly  one   quarter  of  an   inch. 


especially  near  its  posterior  edge  (Figs.  1,  2).  With  a  little 
mucus  in  the  interstices,  the  nostril  is  thus  completely  ob- 
structed, the  opposing  surfaces  doubtless  producing  by  their 
firm  contact  the  sense  of  weight  and  pressure  frequently  ex- 
perienced during  the  progress  of  a  "cold."  A  depression  in 
the  bony  septum  sometimes  corresponds  to  a  protuberance 
of  the  cavernous  tissue  as  if  it  had  yielded  to  repeated 
pressure. 

1  For  a  description  of  some  of  its  various  appearances,  see  paper  by 
Dr.  Cutter  in  the  Boston  JNledical  and  Surgical  Journal,  vol.  Ixxiii.  p.  397. 

2  The  same  as  Fig.  1,  magnified  two  diameters. 


TURBINATED  CORPORA  CAVERNOSA. 


O  -I   < 

ol. 


If  inflated  and  dried,  the  cells 
project  upon  the  surface.  A  section 
(Figs.  1,  2,  and  3)  then  gives  fur- 
ther evidence  of  a  cavernous  struc- 
ture, with  closely  juxtaposed  cavi- 
ties tolerably  uniform  in  size  and 
equally  distributed,  approaching 
quite  nearly  both  the  mucous  sur- 
face and  the  bone.     They  commu- 


Fig.  4.2 


Fig.  3.1 

nicate  by  irregular 
apertures,  while 
minute  bands  and 
septa  traverse  and 
connect  their  com- 
mon walls.  A  wet 
microscopic  section 
(Fig.  4)  exhibits  thin 
trabeculae  and  walls, 
composed  mainly  of 
connective  tissue, 
presenting  cavities 
of  unequal  dimen- 
sions, and  closely  re- 
sembling the  caver- 
nous structure  of  the 
penis,  although    the 


1  Turbinated  corpora  cavernosa  injected  with  gelatine  and  seen  from 
behind.     The  injected  and  thickened  septum  is  also  seen. 

2  Section  of  posterior  extremity  of  a  turbinated  corpus  cavernosum, 
hardened  in  alcohol,  treated  with  iodine  and  glycerine,  and  magnified 
ninety  diameters,  showing  cavities,  walls,  and  trabeculae.  For  this  sec- 
tion I  am  indebted  to  Dr.  A.  N.  Blodgett,  and  for  the  drawing  to  Dr. 
Quincy. 


314  TURBINATED  CORrORA   CA\T:RN0SA. 

smooth  muscular  element  and  the  tunica  albuginea  of  the 
latter  are  somewhat  more  pronounced,  as  might  be  antici 
pated  from  the  comparative  erectile  tension  of  this  organ. 

The  opaque  and  bulbous  termination  of  a  "helicine  artery," 
once  supposed  to  be  characteristic  of  erectile  tissue,  is  con- 
sidered by  Strieker  to  be  only  an  accidentally  folded  ex- 
tremity of  a  "  vascular  loop. "  It  is  figured  as  a  dilated  loop 
in  Todd  and  Bowman's  Anatomy  and  Physiology  (1856,  p.  6), 
where  the  drawing  is  taken  from  the  olfactory  membrane  of 
the  human  foetus.     Observers  differ  about  the  dilatation. 

Everybody  is  familiar  with  the  firm  and  sudden  impaction 
of  the  nose  in  acute  catarrh,  and  has  learned  that  a  swallow 
of  water,  a  pinch  of  snuff,  a  sudden  start,  mental  or  physi- 
cal, often  clears  the  passage,  to  be  again  filled  up.  Medical 
men  have  usually  taken  for  granted,  as  a  satisfactory  solu- 
tion of  these  phenomena,  the  existence  of  a  "congested 
mucous  membrane  " ;  and  to  explain  this,  allege  an  excep- 
tional vascularity  of  this  membrane,  numerous  and  large 
veins,  "venous  plexuses,"  "cavernous  venous  plexuses," 
any  one  of  which  would  be  in  fact  sufficient  to  distend  a 
loose  texture. 

It  is  plain  that  either  of  the  structures  here  enumerated 
might  be  artificially  distended  by  the  anatomist,  with  fluids 
or  with  air.  But  let  it  be  remarked  that,  if  what  is  desig- 
nated as  a  "  venous  plexus  "  resembles  the  choroid  plexus,  it 
consists  of  a  bundle  or  skein  of  hollow  loops  or  vessels, 
inside  of  which  the  blood  circulates  as  usual,  and  is  not  a 
tissue  of  solid  trabeculse  outside  of  which  the  blood  collects 
in  irregular  cavities,  as  in  the  corpora  cavernosa  and  spon- 
giosa  of  the  penis.  In  short,  while  obstruction  of  the  nasal 
fossae  is  familiar,  explanation  of  its  machinery  has  been 
neither  uniform  nor  wholly  satisfactory. 

In  the  following  quotations  from  the  principal  anatomists 
who  have  given  attention  to  this  subject,   it  will  be  found 


TURBINATED   CORPORA  CAVERNOSA. 


315 


Fig.  5.1 


that  the  erectile  action  is  attributed  to  the  existence  of  a 

"venous  plexus"  or  of  a  "cavernous  venous  tissue,"  —  in 

short,  to  enlarged  vessels   rather   than  to 

well  developed  "  corpora  cavernosa. "     Even 

Ivohlrausch, — the  chief  authority  on  this 

point,  whose  early  investigations  best  cover 

the  ground  and  are  most  quoted,  —  figures 

only   a   section   of    distensible   loops   and 

veins  traversing  a  dense  structure  in  which 

they  are  separated  from  each  other  (Figs. 

5  and  6).     I  have  become  acquainted  with 

these  various    investigations   for  the  first 

time  in  looking  up  the  subject  since  my  own  preparations 

here  figured  were  made. 

Hyrtl,  to  whom  Kohlrausch  refers,  says,  "The  veins  of 
the  mucous  membrane  form  plexuses  which 
remind  one  of  the  relation  of  the  veins  in 
the  cavernous  bodies. "  ^ 

KoUiker  affirms  that  "the  thickness  of 
the  mucous  membrane  of  these  parts  is  not 
solely  dependent  upon  the  glands,  but  also 
particularly  on  the  edge  and  the  posterior 

end  of  the  lower  turbinated   bone,  and  upon  the   abundant 

venous  plexuses  of  almost  cavernous  character  discovered  by 

me  in  the  interior  of  the  same;  so  that  a  sort  of  erectile 

tissue  exists  here." 

Lastly,  in  Miiller's  Archiv  (1853,  p.  149)  occurs  the  com- 
munication  from   Kohlrausch  mentioned   above,   and   from 

which  the  following  is  taken :  "  The  simplest  means  of  per- 


1  (From  Kohlrausch.)     "  Venous  loops  "  injected. 

2  (From  Kohlrausch.)  Section  of  venous  loops,  showing  the  so  called 
"  cavernous  venous  tissue  "  and  "  cavernous  cellular  tissue  "  of  Kohlrausch, 
consisting  of  "  firm  cellular  tissue  uniting  vascular  loops." 

3  Topographical  Anatomy,  i.  285. 


316  TURBINATED  CORPORA  CAVERNOSA. 

suading  one's  self  of  the  jiresence  of  this  cavernous  venous 
network,  which  is  particularly  developed  upon  the  posterior 
portion  of  the  turbinated  bone,  is  by  inflating  it  with  air. 
By  hardening  such  an  inflated  preparation  in  alcohol,  we 
may  get  very  good  sections  for  observation.  This  cavernous 
venous  tissue  is  beautifully  injected  at  times,  when  the  injec- 
tion succeeds,  by  inserting  a  tube  in  one  of  the  jugular  veins. 
From  such  preparations  the  drawings  (Figs.  5  and  6)  are 
taken.  The  venous  network,  joined  throughout  by  alnindant 
anastomoses,  lies  between  the  periosteum  and  the  mucous 
membrane,  and  is  everywhere,  in  a  distended  condition, 
li_2'"  thick.  The  venous  loops,  in  their  main  direction, 
are  vertical  to  the  bone,  showing  in  the  injected  condition, 
a  thickness  of  ^-^"',  and  have  tolerably  firm  and  thick 
walls.  A  firm  cellular  tissue  unites  the  vascular  loops  with 
one  another,  so  that  on  section  we  see  merely  a  cavernous 
cellular  tissue ;  we  can  obtain  such  a  specimen  (Fig.  6)  only 
by  a  careful  and  successful  experiment." 

It  would  seem  from  this  description  that  Kohlrausch, 
observing  that  the  turbinated  tissue  could  be  inflated  with 
air,  endeavored  to  throw  into  it  a  common  injection  from 
the  jugular  vein.  This  injection  failed  to  reach  the  caver- 
nous cells.  But  it  did  distend  veins  and  loops  which  were 
adopted  and  figured  by  Kohlrausch  as  the  mechanism  of  erec- 
tion. These  veins  and  loops  represented,  as  he  erroneously 
supposed,  the  structure  he  had  previously  observed,  on 
section,  in  the  alcoholic  preparations,  and  are  offered  by 
him  as  such. 

It  will  be  perhaps  conceded  that  physicians  are  not  gen- 
erally familiar  with  this  anatomy,  of  which  they  will  readily 
make  a  practical  application;  and  lest  injustice  should  be 
done  to  the  investigations  of  twenty  years  ago,  the  text  and 
figures  of  Kohlrausch  are  here  carefully  reproduced. 


EXSTROPHY  OF  THE  BLADDER.  317 


NEW  METHODS  IN  THE  TREATMENT  OF  EXSTROPHY 
OF  THE  BLADDER  AND  OF  ERECTILE  TUMORS.i 

I.  —  Exstrophy  of  the  Bladder  :  Operation. 

This  operation  consists  in  removing  the  exposed  mucous 
membrane  of  the  bladder,  so  that  flaps  drawn  from  the  adja- 
cent skin  may  adhere  directly  to  its  raw  surface.  In  the 
case  detailed  below,  the  mucous  membrane  was  removed 
down  to  the  ureters.  Flaps  drawn  from  the  sides  were  then 
united  on  the  median  line.  Uuion  was  solid  in  about  ten 
weeks.  The  usual  surgical  resource  for  this  sad  malforma- 
tion has  been  an  attempt  only  to  cover  the  mucous  mem- 
brane. But  it  would  seem  better  to  obliterate  it  by  one  and 
the  same  operation  than  to  form  a  cavity  which  is  worse  than 
useless,  because  it  collects  the  salts  of  the  urine. 

The  usual  operation,  of  which  a  case  is  given  below,  also 
needs  a  more  extended  dissection.  It  requires  that  a  first 
flap  be  turned  down  upon  the  bladder  from  above,  the  object 
of  which  is  to  secure  a  lining  of  skin  for  the  new  cavity. 
This  flap  is  covered  with  two  others  drawn  from  the  sides 
and  united  upon  the  median  line.  The  denuded  surface 
from  which  the  first  flap  was  taken  is  then  similarly  closed 
by  further  dissections.  By  the  operation  now  proposed,  both 
the  first  flap  and  the  dissection  for  covering  the  surface 
which  supplies  it  are  unnecessary.  In  both  operations  flaps 
are  best  cut  where  the  skin  is  most  relaxed.  Hence  it  is 
better  to  include  in  the  incisions  the  loose  integuments  of 

^  Boston  Medical  and  Surgical  Joiu'nal,  January  6,  1876. 


318 


EXSTROPHY  OF  THE  BLADDER. 


the  f^roin,  and  even  of  the  scrotum.  The  edges  can  then  be 
brought  together  in  any  direction  in  which  the  flaps  yield 
most  readily. 

In  a  third  case  cited  below,  where  the  bladder  (open  over 
the  pubes)  still  presented  a  cavity,  I  was  able  to  close  this, 
so  that  l:)y  wearing  a  truss-pad  the  patient  could  retain  urine 
for  two  hours.  This  case,  however,  was  not  one  of  complete 
exstrophy  like  the  others. 

1  am  indebted  to  Dr.  H.  H.  A.  Beach  for  the  following 
abstract  from  the  hospital  records. 


Fig.  1  1 

Case  I.  Complete  Exstrophy  :  New  Operation.  —  E.  C.  A., 
six  years  old,  presented  a  complete  exstrophy  of  the  bladder, 
which  was  wholly  exposed  over  a  surface  of  two  and  a  half 
inches;  the  skin  was  tense  and  the  abdominal  wall  thin. 
The  testicles  were  still  in  the  inguinal  canal. 

1  Exstrophy  of  the  bladder.  Lines  of  the  incisions.  In  uniting  them 
over  the  dissected  surface  of  the  bladder,  the  points  AAA  were  brought 
together,  and  the  points  B  B ;  the  skin  more  readily  \-ielding  in  a  direc- 
tion obliquely  upward. 


EXSTROPHY   OF  THE   BLADDER. 


319 


December  13,  1874.  Operation  under  ether.  The  mucous 
surface  of  the  exposed  bladder  was  carefully  dissected  off, 
and  the  lateral  flaps,  including  both  inguinal  regions,  were 
united  upon  the  median  line  and  transversely  above  it. 
Sixteen  silver  sutures  were  introduced,  and  a  piece  of  adhe- 
sive plaster  was  placed  over  the  whole  to  keep  the  parts 
immovable  (Fig.  1). 

December  14  and  15.    Patient  doing  well,  with  little  pain. 

December  16.  A  good  deal  of  swelling  about  the  wound, 
with  a  small  slough  near  its  upper  extremity,  where  urine 
oozes. 


^ 


I 
'1 


vvJ 


Fig.  2.1 


December  18.     Pulse    140.      Temperature,    A.    m.,    101°; 
p.  M.,  103°. 

December  21.     Twelve  sutures  removed. 

Remaining  sutures  removed. 
Patient  doing  well.     The  wound  is  healed, 
except   at    its    upper    extremity,    where    there   is   a   little 
discharge. 

1  Photograph  after  the  parts  had  healed. 


December  22. 
December  25. 


320  EXSTROPHY  OF  THE  BLADDER. 

January  22,  1875.  A  small  abscess  is  forming  under 
the  flap.     Patient  has  had  a  slight  convulsion. 

January  25.  Abscess  discharged  through  one  of  the 
needle  holes. 

January  26.  Edges  separated  a  little  by  ulceration  at 
the  upper  extremity. 

March  1.     Patient  is  running  about. 

March  12.     Photograph  taken. 

April   10.     Union  solid  and  no  tenderness  remaining. 

May  7.   Discharged,  well  (Fig.  2). 

Case II.  Complete  Exstrophy :  Old  Operation.  — C.  P.,  aged 
seventeen,  entered  the  Hospital  with  complete  exstrophy. 
Above  the  symphysis  was  a  pulpy  vascular  and  florid  swell- 
ing, two  and  a  half  inches  in  diameter,  formed  by  the  pro- 
truded mucous  surface  of  the  posterior  wall  of  the  bladder. 
The  umbilicus  was  wanting;  no  hernia  existed,  and  the 
testicles  had  descended.  The  surface  was  very  sensitive  and 
tender,  the  penis  rudimentary,  with  a  complete  epispadias. 
The  urine,  distilled  from  the  ureters,  fell  upon  the  urethra, 
which  served  imperfectly  as  a  spout.  The  patient  was 
anxious  and  suffering.  A  shield  covering  the  part  caused 
excoriation. 

June  2,  1868.  Operation,  under  ether.  A  transverse 
incision  midway  between  the  bladder  and  the  sternum,  with 
vertical  incisions  at  its  extremities,  surrounded  three  sides 
of  a  flap,  of  which  the  hinge  was  next  the  bladder.  The 
flap  was  turned  down  over  the  bladder  as  far  as  the  penis. 
Additional  transverse  incisions  were  now  made,  and  four 
side  flaps  were  dissected  up,  two  of  them  abreast  of  the 
bladder,  and  two  on  a  level  with  the  wound  from  which  the 
first  flap  was  taken.  These  four  flaps  were  now  drawn  to 
the  median  line  and  united,  two  serving  to  cover  the  raw 
surface  of  the  inverted  flap,  and  two  that  of  the  region  from 


EXSTROPHY  OF  THE   BLADDER.  321 

which  it  was  taken.  The  wound  was  everywhere  closely 
united  by  silver  sutures. 

June  3.  Patient  quite  comfortable,  sleeping  in  a  sitting 
posture  to  encourage  the  escape  of  urine.  Flaxseed  tea  and 
milk  ad  libitum. 

June  7.  Doing  well.  Appetite  good.  Takes  an  opiate 
at  night.  The  parts  in  the  neighborhood  of  the  wound  are 
carefully  washed  night  and  morning,  the  salts  of  the  urine 
removed,  and  the  skin  protected  by  castor  oil. 

June  11.     Half  the  silver  sutures  removed. 

June  16.  Patient  sits  up  nearly  the  whole  day,  and  has  an 
excellent  appetite.  Flaps  are  united  beneath,  while  the 
edges  are  looking  well,  though  there  is  little  union  by  first 
intention. 

June  18.  Sutures  all  removed.  Patient  says  that  he  is 
much  more  comfortable  than  before  the  operation.  The  most 
troublesome  feature  of  the  case  is  the  deposition  of  salts  of 
the  urine  upon  the  scrotum. 

June  26.  Margins  pretty  well  united.  All  the  urine 
escapes  just  over  the  glans  penis. 

July  7.     Doing  finely.       Walks  about. 

August  20.  Cicatrization  complete.  Bladder  wholly 
covered.  Condition  far  more  comfortable  than  before  the 
operation.     Discharged. 

Case  III.  Orifice  above  the  Pubes  :  Operatioti.  — F.  W., 
aged  sixteen.  Just  above  the  symphysis  pubis  there  exists 
an  orifice  almost  an  inch  in  diameter,  circular,  and  in  part 
occupied  by  a  rudimentary  glans  penis.  There  are  no 
hernise,  and  both  testicles  have  descended.  In  the  erect 
posture  the  urine  constantly  dribbles  away.  When  the 
patient  is  lying  down  the  urine  collects  in  the  bladder  un- 
til it  overflows. 

November  7,  1868.     Operation,  under  ether.     The  edges 

21 


322  ERECTILE  TUMORS. 

of  the  aperture  and  frsenum  were  refreshed,  dissected  up,  and 
joined  with  six  silver  sutures ;  the  orifice  was  reduced  so  as 
to  embrace  tightly  a  piece  of  elastic  catheter  passed  into  the 
bladder. 

Xovember  11.  Wound  suppurating  a  little.  Glans  penis 
at  times  enlarged,  and  trying  to  escape  through  the  small 
orifice  left  from  the  operation. 

Xovember  12.  Catheter  no  longer  worn.  Union  perfect. 
Urine  escapes  wholly  through  the  small  aperture. 

December  30.     Patient  has  a  sharp  attack  of  epididymitis. 

January  2.      Improving. 

March.  Patient  discharged,  well.  Retains  urine  for  two 
hours  by  means  of  an  apparatus  consisting  of  a  truss  spring 
around  the  pelvis,  to  the  back  of  which  a  steel  spring  is 
attached  passing  between  the  legs  and  terminating  in  a  pad 
which  compresses  the  aperture  in  front. 

II.  —  Erectile  Tumors  obliterated  by  Central  Cauteriza- 
tion WITH  Solution  of  Nitrate  of  Silver. 

In  each  of  the  following  instances  erectile  tumors  of  a  for- 
midable nature  were  easily  obliterated  by  the  injection,  with 
a  subcutaneous  syringe,  of  a  few  drops  of  a  solution  (equal 
parts  by  weight)  of  nitrate  of  silver  in  water.  If  the  tissues 
are  firmly  compressed  about  the  orifice  of  the  tube,  after  its 
introduction,  an  eschar  of  the  solid  tissues  is  produced,  soon 
enveloped  by  coagulum  adherent  from  inflammation,  with 
general  blood  stasis  in  the  neighborhood.  While  the  eschar 
thus  made  is  more  distinct  and  firm  than  that  by  acid  or  by 
the  perchloride  of  iron,  the  expulsion  of  the  blood  probably 
diminishes  the  danger  of  embolism.  The  ultimate  result  is 
abscess  and  solid  cicatrization.  The  first  of  the  following 
cases  was  one  of  a  large  and  pendulous  under  lip,  which  was 
so  solidified  by  a  number  of  simultaneous  injections  that  a 
V-shaped  portion  was  finally  removed  from  it.     The  second 


ERECTILE   TUMORS.  323 

was  one  of  cirsoid  aneurism  in  the  cavity  of  the  orbit,  which 
could  not  have  been  treated  effectually  by  ligature  without 
sacrificing  the  eye. 

Case  I.  Pulsating  Ncevus  of  the  Lips  and  Face  ;  Opera- 
tion ;  Cure.  — A.  E.,  female,  aged  thirty-six,  has  a  congen- 
ital nsevus,  involving  the  whole  of  the  chin  and  lower  lip  and 
the  inside  of  the  upper  lip,  with  a  claret-colored  stain 
extending  over  both  cheeks  as  far  as  the  ears.  The  lower 
lip  and  the  chin  are  largely  hypertrophied  and  pendulous, 
pulsating  when  compressed. 

November  24,  1868.  Operation.  The  patient  was  ether- 
ized, and  the  inside  of  the  whole  upper  lip  strangulated  by 
seven  large  needles  carrying  fourteen  ligatures. 

January  10,  1869.  Wound  of  upper  lip  entirely  healed 
and  tissues  contracted. 

February  23.  Operation.  The  patient  having  been  ether- 
ized, a  few  drops  of  a  saturated  solution  of  nitrate  of 
silver  were  injected  by  a  subcutaneous  syringe  at  eight 
several  places  in  the  thickness  of  the  lower  lip,  the  lat- 
ter being  compressed  upon  the  point  of  the  syringe  during 
the  injection. 

February  24.  The  patient  complains  of  pain  extending 
down  both  sides  of  the  neck.     Lip  much  swollen. 

February  28.  Little  pain;  free  discharge  from  the  open- 
ings ;  lip  swollen  and  hard. 

March  5.  Several  small  sloughs  have  come  away,  leaving 
cavities  beneath  the  skin.  From  this  time  the  lip  contracted, 
puckering  at  the  injected  points  until  the  whole  was 
solidified. 

April  6.  Operation.  The  patient  having  been  ether- 
ized, a  Y-shaped  piece  was  excised  from  the  centre  of  the 
lip,  with  very  little  hemorrhage  except  from  the  coronary 
arteries. 


324  ERECTILE  TUMORS. 

May  2.  Patient  was  discharged  with  a  lip  of  nearly 
normal  size. 

Case  II.  Cirsoid  Aneurism  of  the  Orbit ;  Operation ; 
Cure.  —  H.  McC. ,  housemaid,  aged  twenty-five,  noticed  in 
1868  a  small  pulsating  swelling  at  the  inner  angle  of  the 
left  orbit.  Now  a  pulsating  tumor  of  the  size  of  a  large 
almond  extends  from  the  supra-orbital  notch  to  the  bridge 
of  the  nose,  and  backward  between  the  globe  and  the  orbit. 
It  has  increased  rapidly  of  late,  and  the  mass  has  a  feeling 
like  that  of  enlarged  and  convoluted  arteries.  Pulsation 
is  strong  and  heavy,  with  a  thrill,  diminished  but  not  ar- 
rested by  compression  at  various  points  of  the  tumor's  cir- 
cumference. Compression  of  the  carotid  does  not  materially 
affect  the  pulsation. 

October  17,  1874.  Operation.  Three  drops  of  a  saturated 
solution  of  nitrate  of  silver  were  injected  into  the  centre  of 
the  tumor  by  a  subcutaneous  syringe.  Before  the  injection 
the  tumor  was  firmly  compressed  against  the  bone  above  the 
orifice  of  the  syringe,  and  held  there  for  a  minute  or  two 
afterwards.  A  marked  venous  congestion  was  immediately 
noticed  in  the  vicinity  of  the  tumor. — P.  M.  The  swelling 
has  extended  to  the  frontal  region ;  eyelid  congested. 

October  18.  Tumor  perfectly  hard,  without  pulsation. 
Left  eye  closed  by  the  swelling  of  the  lids.  The  latter 
were  scarified.     Some  frontal  headache. 

October  23.  Lids  opening.  General  swelling  diminished ; 
red  but  less  tender. 

October  29.  Swelling  larger  and  fluctuating.  Eye  again 
closing. 

October  30.  Gland  in  front  of  right  ear  and  one  under 
left  jaw  swollen  and  tender.  Pulse  100.  Temperature 
99.5°. 

November  4.     Temperature  normal.     The  site  of  the  tumor 


ERECTILE  TUMORS.  325 

is  occupied  by  a  large  and  fluctuating  swelling.  Glycerine 
plasma  was  applied  over  the  tumor  to  soften  the  cuticle  where 
the  pus  seemed  to  be  pointing. 

November  5.  The  abscess  was  spontaneously  evacuated 
near  the  inner  canthus. 

November  12.  The  patient  was  discharged  at  her  own 
request. 

December  12.  The  patient  returned  for  examination. 
The  place  filled  by  the  tumor  is  now  occupied  by  a  firm 
cicatrix  everywhere  adherent  to  the  bone. 


326  REPAIR  OF  TISSUE. 


THE   MODERN  ART   OF   PROMOTING   THE  REPAIR 
OF  TISSUE.  1 

The  new  art  of  promoting  repair  of  the  animal  tissues 
combines  the  so  called  antiseptic  method  with  other  expedi- 
ents hardly  less  important.  Its  object  is  to  facilitate  cell 
growth  and  cell  transformation.  This  it  accomplishes  in  a 
remarkable  manner. 

Antiseptics  arrest  decomposition  in  all  stages,  —  not  only 
advanced  decomposition,  characterized  by  odor,  but  also  the 
beginning  of  the  process,  which  dates  from  the  introduction 
of  germs  through  the  atmosphere.  With  germs  we  have 
putrefaction  or  fermentation ;  without  them  we  have  none. 
These  germs  float,  in  small  proportion,  among  the  particles 
which  are  visible  in  a  sunbeam.  The  object  of  the  anti- 
septic method  is  either  to  destroy  their  vitality,  or,  by  filter- 
ing the  air,  to  exclude  them.  The  process  gets  to  be  a 
matter  of  routine,  and  of  a  dozen  methods  of  accomplishing 
it  there  will  always  be,  as  at  the  present  time,  a  best  and 
latest  one.  But  whatever  be  the  means  employed,  no  half 
measures  suffice. 

I  doubt  whether  any  surgeon  approaches  certain  machinery 
of  the  antiseptic  method  for  the  first  time  without  distaste. 
It  flatters  neither  the  vanity  nor  the  scientific  sense  to  exor- 
cise an  invisible  enemy  with  something  very  like  a  censer. 
But  after  two  years'  experience  1  have  accepted  the  new 
doctrine  with  most  of  its  details.     I  have  learned  that,  what- 

1  A  Lecture  delivered  before  the  Medical  Class  of  Harvard  University, 
in  1876.     Boston  Medical  and  Surgical  Journal,  June  5,  1879. 


REPAIR  OF  TISSUE.  327 

ever  be  his  method,  the  duty  of  the  surgeon  is  to  act  as  if  all 
the  particles  made  visible  by  a  sunbeam  were  noxious,  falling 
like  snow-flakes  during  every  operation  and  every  dressing, 
seeking  to  insinuate  themselves  into  the  wound  at  every 
crevice.  His  aim  should  be  to  destroy  the  actual  intruders, 
and  effectually  to  exclude  their  thronging  companions. 

While  partial  measures  facilitate  repair,  and  a  pure  air 
promotes  it,  there  can  be  no  question  that  the  average  result 
is  signally  improved  by  a  thorough  "antiseptic"  dressing, 
and  that  the  worst  cases  often  thrive  under  it  in  a  way  hith- 
erto wholly  unexampled. 

Let  us  first  give  the  credit  of  this  new  art  to  Mr-  Lister, 
and  then  look  briefly  at  the  theory  and  its  surroundings. 

Like  other  germs,  the  germ  of  knowledge,  in  the  form  of 
suspicion  and  hypothesis,  is  always  floating  in  the  air.  He 
who  first  assembles  imperfect  and  detached  ideas,  and  by 
their  means  establishes  a  proposition  beyond  a  doubt,  and 
then  brings  his  demonstration  home  to  the  conviction  of  the 
world,  —  a  measure  which  is  all-important  to  his  claim,  — 
has  fulfilled  every  condition  essential,  not  only  to  the  pri- 
vate and  secret  discoverer,  who  has  no  claim  to  the  world's 
gratitude,  but  also  to  the  public  discoverer,  who  lays  the 
world  under  obligation,  and  is  on  that  account  recognized 
by  it. 

Lister  is  entitled  to  the  merit  of  inventing  a  new  and 
invaluable  system  of  promoting  repair.  Antiseptics  and 
drainage  had  indeed  long  been  known,  but  upon  these  expe- 
dients Lister  erected  an  entire  art,  developed  it,  and  taught 
it  with  untiring  perseverance  till  it  was  recognized.  To 
Lister's  hypothesis  belongs  the  additional  merit  of  being  no 
accident.  It  had  a  distinctly  scientific  source  in  the  experi- 
ments of  Pasteur. 

Pasteur,  as  many  of  you  know,  showed  that  decomposition 


328  REPAIR  OF  TISSUE. 

occurs  only  where  certain  microscopic  organisms  are  present. 
He  further  showed  that  the  germs  of  these  organisms  always 
exist  in  the  atmosphere,  and  that  the  organisms  reproduce 
themselves.  If  you  exclude  them,  decomposition  does  not 
take  j)lacc,  and,  so  far  as  we  know,  cannot  do  so. 

Tyndall  repeated  Pasteur's  experiments.  His  glass  box 
is  familiar.  Painted  inside  with  some  adhesive  substance, 
it  was  allowed  to  stand  until  the  particles  in  the  contained 
air  had  settled  or  adhered.  When  a  ray  of  light,  traversing 
the  box,  showed  that  there  were  no  particles  to  be  illumi- 
nated, decomposition  no  longer  occurred  therein.  Any  ani- 
mal or  vegetable  fluid  sterilized  by  heat  might  remain  in 
it  for  months  unchanged.  On  admitting  the  atmosphere, 
with  its  dust  glistening  in  the  sunbeam  or  the  electric  ray, 
organic  fluids  became  at  once  putrid. 

There  is  another  familiar  and  more  curious  experiment. 
Let  an  organic  fluid  be  placed  in  a  test  tube,  the  mouth  of 
which  is  attenuated  for  a  few  inches  and  bent  to  a  zigzag 
form,  but  left  open.  The  air  drawn  in  and  out,  as  the  tem- 
perature changes,  seems  to  lodge  and  leave  its  germs  at  the 
angles.  At  any  rate,  in  such  a  tube  boiled  urine  will  not 
putrefy  for  years.  Break  the  little  tube  so  as  to  admit  air 
freely  with  its  particles,  and  putrefaction  occurs  at  once. 
This  experiment  is  the  more  curious  because  it  would  seem 
probable  that  the  germs  cannot  be  all  excluded  from  the  tube, 
but  that  a  few  must  pass  in  when  the  cavity  inspires  air  at 
every  decrease  of  temperature,  —  just  as  dust  insinuates  itself 
under  the  crystal  of  a  watch,  or  beneath  a  picture  frame, 
streaking  the  engraving. 

Whether  we  filter  the  air,  and  so  strain  off  the  particles, 
or  annul  their  influence  by  antiseptics,  or  by  extremes  of 
heat  and  cold,  the  result  is  the  same.  Canned  provisions 
are  first  boiled,  and  then  hermetically  sealed.  The  cook 
boils  the  syrup  or  ketchup,  or  roasts  the  meat,  to  keep  them 


REPAIR   OF   TISSUE.  329 

from  spoiling.  Refrigerators  are  necessities  of  civilized  life ; 
and  the  modern  brewer  consumes  many  thousand  tons  of  ice 
to  cool  his  beer  to  a  point  which,  while  it  allows  fermenta- 
tion to  go  on,  will  prevent  an  acetic  or  other  unwished  for 
change,  and  so  keep  it  from  spoiling. 

The  change  here  alluded  to  is  a  form  of  fermentation.  All 
fermentation  is  distinguished  by  the  fact  that  the  height  of 
the  process  is  characterized  by  the  greatest  abundance  of 
little  organisms.  When  the  fermentation  is  over,  they  die 
and  fall  to  the  bottom,  and  the  liquid  becomes  clear.  This 
happens  also  during  putrefaction,  and  is  considered  evidence 
that  the  latter  may  be  a  form  of  fermentation,  dependent  on 
the  presence  of  a  bacterium  developed  from  a  germ.  Just  as 
the  fermentation  of  beer,  for  example,  depends  upon  the  pres- 
ence of  yeast,  so  putrefaction  depends  upon  another  ferment, 
of  which  particles  floating  in  the  air  are  the  seeds. 

But  even  if  the  germ  should  prove  to  be  not  the  seed  of  a 
ferment,  but  only  a  coincident  which  science  has  been  unable 
to  separate  from  some  other  and  essential  mechanism  of 
putrefaction,  it  is  nevertheless  its  infallible  measure  and 
indication,  and  this  is  all  the  surgeon  needs  to  know.  He 
may  be  satisfied  with  the  practical  deduction  that  to  prevent 
decomposition  in  a  wound  he  must  prevent  the  entrance  of 
the  active  particles  of  the  air. 

Let  us  here  dwell  a  little  on  the  germ  theory  of  diseases, 
which  is  sometimes  discussed  in  this  connection  as  a  branch 
of  the  same  subject.  We  have  seen  that  putrefaction  is 
doubtless  one  form  of  fermentation,  just  as  the  change  under- 
gone by  wine,  beer,  and  vinegar  is  another  form.  Now,  be- 
cause certain  diseases  have,  like  fermenting  fluids,  a  period 
of  incubation,  of  activity,  culmination,  and  decline,  and  be- 
cause they  exactly  reproduce  themselves,  or  "breed  true," 
it  has  been  argued  that  they  are  also  dependent  upon  some 
form  of  germ  or  ferment.     And  because  in  a  very  few  dis- 


330  REPAIR   OF   TISSUE. 

eases,  notably  in  splenic  fever,  Davaine  and  Pasteur  have 
detected  not  only  bacteria,  but  distinctive  ones,  essential  to 
the  disease,  it  has  been  assumed  that  all  epidemics  travel 
by  the  floating  germs  of  their  own  bacteria. 

Further  than  this,  it  has  been  maintained  that,  if  common 
decomposition  and  epidemics  are  alike  due  to  germs,  then 
localities  which  are  known  to  harbor  and  breed  the  germs  of 
the  one  will  be  likely  to  harbor  and  breed  those  of  the 
other ;  for  example,  that  in  a  case  of  diphtheria  or  typhoid 
fever  drains  or  water-closets  where  matter  is  resolving  itself 
into  its  elements  are  most  likely  to  harbor  and  breed  the 
germs  of  these  diseases  with  others. 

A  dung-heap  near  a  well  was  supposed  to  explain  a  typhoid 
epidemic  among  those  who  drank  the  water.  More  remark- 
able still,  an  alleged  typhoid  epidemic  among  the  customers 
of  a  certain  milkman  was  said  to  be  caused  by  the  infection 
of  his  milk-cans,  because  they  were  washed  in  a  river  which, 
a  mile  or  two  above,  flowed  past  a  small  quantity  of  human 
excrement  from  a  typhoid  patient  on  the  banks.  In  consid- 
ering such  suppositions,  we  must  not  forget  the  array  of 
negative  facts  that  render  them  doubtful. 

If  by  "material"  agencies  of  disease  we  mean  that  its 
proximate  cause  occupies  space  and  moves  in  it,  we  may  be 
correct.  The  bulk  of  one  spermatozoon  may  suffice  to  contain 
billions  of  specific  atoms.  But  it  is  quite  another  question 
whether  an  eye  or  lens  will  ever  be  able  to  identify  in  the 
spermatozoon  either  the  hereditary  germ  or  the  predisposing 
soil  of  gout,  because  it  has  discovered  the  bacterium  of  splenic 
fever,  or  the  spore  of  pityriasis  versicolor,  or  the  itch  insect, 
or  the  flea,  or  the  African  lion  which  follows  an  Arab  vil- 
lage, or  any  other  organism  which  gets  its  living  directly 
or  indirectly  off  the  human  race,  singly  or  collectively, 
and  is  to  that  extent  parasitic  and  noxious.  We  cannot  too 
strongly  remember  that  something  very  like  decomposition 


REPAIR   OF  TISSUE.  331 

is  going  on  everywhere  inside  and  outside  the  human  body, 
and  that  it  does  not  usually  produce  any  insidious  effect. 

It  is  proper  to  enjoin  cleanliness  and  the  removal  of  obvi- 
ously predisposing  causes,  even  without  deciding  whether 
the  germs  of  diphtheria,  or  scarlatina,  or  yellow  fever,  in- 
fect a  drain  with  their  bacteria,  or  whether  they  develop  in 
preference  in  the  all-surrounding  air,  and  thence  devastate 
a  town,  or  cross  a  continent,  under  conditions  of  which  we 
know  little. 

I  am  quite  willing  to  avow,  after  two  years  spent  in  devis- 
ing new  antiseptic  details,  most  of  which  you  have  seen  in  the 
surgical  wards,  that  I  have  come  back  to  something  very  like 
Lister's  method  as  the  most  convenient  and  efficient. 

As  no  doubt  some  of  you  will  be  likely  to  try  for  your- 
selves experiments  in  this  direction,  and  faulty  ones  per- 
haps, I  cannot  do  better  than  briefly  to  refer  to  some  of  my 
own,  with  the  reasons  for  them. 

Disinfectants  act  in  two  ways.  For  example,  chloride  of 
zinc  and  salicylic  acid  act  only  by  contact,  and  give  out  no 
disinfectant  atmosphere.  On  the  other  hand,  burning  sul- 
phur, chloride  of  lime,  solutions  of  chlorinated  soda  and 
carbolic  acid,  have  a  great  advantage  in  generating  a  gas  or 
vapor  which  disinfects  the  surrounding  atmosphere. 

Some  of  us  remember  that  during  the  war  travelling 
agents  professed  to  preserve  corpses.  A  person  of  this 
description  came  to  our  dissecting-room,  and  by  merely 
painting  the  surface  and  injecting  the  orifices  of  a  dead  body 
with  a  colorless  liquid  preserved  the  muscles  from  putre- 
faction for  a  period  of  six  weeks  in  the  months  of  July  and 
August.  I  soon  found  this  "paint"  to  be  carbolic  acid. 
Its  extraordinary  preservative  properties,  which  are  easily 
demonstrated  upon  meat,  make  it  on  the  whole  the  best 
antiseptic  for  surgical  use. 


332  REPAIR  OF  TISSUE. 

Mr.  Lister's  first  article  was  published  in  the  spring  of 
1865.  In  the  autumn  of  that  year,  Dr.  Beach,  then  my 
house  surgeon,  dressed  a  couple  of  amputations  in  the  way 
described  by  Lister.  They  did  well.  But  other  dressings 
did  well  also,  so  that  the  new  method  was  abandoned. 

Two  years  ago,  however,  the  evidence  had  so  accumu- 
lated that  I  set  fairly  to  work  to  try  the  experiment  again, 
beginning  with  what  seemed  the  most  reasonable.  I  thor- 
oughly washed  lesions  and  wounds  in  a  carbolic  solution, 
covered  them  with  a  cloth  similarly  wet,  and  then  with 
rubber  cloth  to  hinder  evaporation.  They  did  better  than 
those  otherwise  treated. 

My  next  step  was  to  introduce  the  distinctive  principle  of 
non-disturbance.  The  late  Dr.  James  Jackson  remarked  to 
me  when  a  student,  that  he  was  satisfied  that  surgeons  were 
mistaken  in  adopting  the  then  prevailing  notions  in  regard 
to  dressing  wounds.  He  had  himself  seen  better  results  when 
a  wound  was  undisturbed,  even  at  a  sacrifice  of  cleanliness, 
than  when  it  was  daily  dressed.  It  was  in  pursuance  of 
this  hint  that,  more  than  twenty-five  years  ago,  as  I  was 
lately  reminded  by  a  former  house  surgeon,  unless  there 
were  untoward  symptoms,  I  usually  left  the  bandages  upon 
an  amputation  so  long  as  a  solution  of  chlorinated  soda 
frequently  applied  to  the  outside  would  keep  them  odorless. 
The  rule  of  non-disturbance  was  here  enforced.  Consider 
for  a  moment  what  must  be  the  tendency  of  an  opposite 
treatment,  when  newly  formed  cells  are  daily  washed  with 
alkaline  soap,  perhaps  dabbed  with  a  sponge,  or  killed  by  a 
mass  of  charpie  saturated  with  some  alcoholic  solution  to 
stimulate  them.  It  is  a  little  remarkable  that  under  vsuch 
treatment  wounds  heal  at  all.  In  short,  I  was  early  persuaded 
that  the  menstruum  best  adapted  to  the  multiplication  and 
transformation  of  cells  was  the  fluid  in  which  they  are  nor- 
mally found,  —  that  a  pus  or  lymph  dressing  was  the  best ; 


REPAIR   or  TISSUE.  333 

and  my  efforts  were  directed  towards  keeping  this  pus  from 
decomposition.     I  now  again  attempted  this. 

A  compress,  wet  as  before  in  a  carbolic  solution  of  one  in 
sixty  was  applied  to  a  wound,  and  covered  with  rubber  to 
prevent  evaporation.  Beneath  it  a  tube  was  inserted  for  the 
injection,  twice  a  day,  of  the  same  carbolic  solution.  This 
dressing  could  be  left  without  renewal  for  a  week.  But  the 
trouble  of  frequent  injection  was  not  its  only  imperfection. 
The  surface  of  a  cloth  is  too  rough  and  absorbent  to  be 
placed  in  contact  with  growing  cells,  and  they  will  be  seen  to 
multiply  faster  after  the  cloth  has  been  floated  oif  the  surface 
by  a  thin  layer  of  pus.  To  obviate  this  difficulty,  gold-beaters' 
skin  was  interposed  in  contact  with  the  granulations.  Its 
soft  surface  was  all  that  could  be  desired ;  but,  unluckily,  two 
days  sufficed  to  dissolve  it.  Carbolized  bladder  was  next 
tried,  and  did  well,  but  proved  a  little  stiff  and  dry.  Curiously 
enough,  the  growing  cells  ("wandering  ")  penetrated  its  moist 
surface,  so  that  when  it  was  raised  they  were  torn  off  and 
bled.  I  now  adopted  the  smooth  but  impenetrable  surface  of 
oiled  silk.  This  answered  admirably,  and  I  had  at  last 
reached  the  expedient  long  before  employed  by  Lister. 

Under  such  a  dressing  a  wound  not  only  exudes  the  thin 
layer  of  fluid  in  which  cells  thrive,  but  its  surface  and  mar- 
gin become  as  uniformly  smooth  and  glassy  as  the  oiled 
silk  which  protects  them.  Such  a  surface  contrasts  strongly 
with  the  inflamed  and  corrugated  exterior  of  a  lesion  dressed, 
for  example,  with  charpie  and  tincture  of  myrrh.  The  cell 
transformation  is  now  the  very  horticulture  of  repair.  The 
pink  cicatricial  edge  rapidly  contracts  around  the  wound. 
Besides  this,  if  you  desiccate  the  surface  by  blowing  upon 
it,  you  discover  a  concentric  glistening  film  of  cuticle,  pre= 
viously  invisible,  which  may  attain,  in  a  large  ulcer,  the 
extraordinary  width  of  a  quarter  to  three  quarters  of  an  inch 
in  a  week,  —  preparing  the  way  for  the  cicatrix  which  fol- 


334 


REPAIR   OF  TISSUE. 


lows.  Such  is  the  result  when  the  surface  has  been  flattened 
and  polished  by  the  glazed  and  impervious  surface  of  oiled 
silk,  while  the  atmospheric  germs  have  been  effectually- 
excluded. 

This  exclusion  being  a  fundamental  condition  of  success, 
we  will  now  consider  the  method  of  its  accomplishment  as 
practised  and  prescribed  by  Lister.  A  diagram  will  make 
this  plain. 


1.  Represents  a  wound  containing  a  drainage  tube. 

2.  Is  a  protective  of  oiled  silk  in  contact  with  the  wound, 
overlapping  its  edge,  and  traversed  by  the  drainage  tube. 

3.  A  layer  of  folded  and  carbolized  muslin,  which  largely 
overlaps  the  protective. 

4.  A  final  layer  of  folded  carbolized  muslin,  containing  a 
thin  rubber  cloth.  The  latter  has  the  distinct  duty  of 
diverting  the  discharge  and  delaying  its  direct  progress  to 
the  surface.  It  thus  retards  decomposition,  which  occurs  in 
the  fluid  soon  after  it  has  soaked  its  way  to  the  air,  and  is 
then  rapidly  communicated  to  the  wound. 

5.  Represents  the  path  of  the  discharged  fluid,  when 
diverted  by  the  rubber  cloth. 

Such  a  dressing  may  be  wrapped  about  the  extremity  of 
a  stump,  or  carefully  fitted  to  the  curved  surfaces  of  the 
chest  and  shoulder,  —  after  excision  of  a  breast,  for  example, 
—  and  the  whole  is  then  bandaged. 

A  dry  spot  of  discharge  appearing  on  the  surface  of  the 


REPAIR  OF  TISSUE.  335 

bandage  may  perhaps  be  overlooked.  But  if  the  discharge 
soaks  through  it,  and  the  stain  grows  larger,  the  whole 
dressing  must  be  renewed  at  once.  This  happens  the  day- 
after  the  operation;  then  perhaps  several  times  in  a  week; 
later,  more  rarely.  It  is  desirable  that  the  carbolized  cover- 
ing should  exert  an  antiseptic  influence  for  many  days,  or, 
as  sometimes  in  a  knee  excision,  for  several  weeks,  without 
renewal.  This  is  the  object  of  the  muslin,  a  porous  and 
cheap  fabric  impregnated  with  carbolic  acid,  which  is  mixed 
with  rosin  to  hold  and  slowly  deliver  it,  and  with  paraffine 
to  make  the  rosin  flexible.^ 

Briefly  to  recapitulate.  The  wound  is  covered  with  oiled 
silk,  and  with  fifteen  or  twenty  layers  of  carbolized  muslin 
containing  a  rubber  cloth,  and  then  bandaged.  Every  pre- 
caution is  taken  to  prevent  the  contact  of  germs,  whether 
during  an  operation  or  a  dressing;  the  wound,  the  skin,  the 
cloths,  the  surgeon's  hands,  the  instruments  and  sponges, 
being  all  repeatedly  washed  in  a  carbolic  solution. 

The  atomizer,  which  blows  a  cloud  of  spray  of  the  strength 
of  one  in  forty  upon  a  wound,  whether  during  an  operation 
or  a  dressing,  is  an  essential  feature  of  Lister's  method.  It 
certainly  adds  nothing  to  the  immediate  comfort  of  the  sur- 
g:eon.  But  it  seems  to  be  an  available  substitute  for  a  part 
of  the  washing  and  slopping  incident  to  the  use  of  anti- 
septics in  a  fluid  form,  and  is  in  that  respect  a  great  con- 

1  The  following  is  the  method  of  making  the  carbolized  muslin :  — 
Crystallized  carbolic  acid     ....     one  part. 

Common  resin five  parts. 

Solid  parafRne seven  parts. 

Melt  the  two  latter  in  a  water  bath,  and  add  the  acid  while  stirring. 
The  muslin  employed  in  our  Hospital  is  of  cotton,  and  known  as  Cole- 
rain,  or  strainer  cloth. 

The  hot  mixture  is  sprinkled  upon  the  muslin  with  a  large  brush.  To 
further  diffuse  the  carbolized  mixture,  the  muslin  is  then  folded  small 
and  subjected  to  pressure  in  a  tin  can  for  several  hours,  at  the  tempera- 
ture of  boiling  water. 


336  llEPAIR  OF  TISSUE. 

vcnience.  This  is  especially  true  of  a  dressing  in  bed.  Its 
efficiency  could  hardly  have  been  anticipated,  but  there  is  no 
reason  to  doubt  it.  Lister  seems  to  have  first  tried  a  jet  of 
fluid. 

The  result  of  a  complete  Lister  dressing,  spray  included, 
is  sometimes  marvellous,  —  as,  for  example,  in  a  resection 
of  the  knee,  which  may  require  to  be  dressed  two  or  three 
times  during  the  first  ten  days,  and  only  as  often  during  the 
next  two  or  three  months. 

Other  methods  will  in  time  doubtless  supersede  it,  but 
there  is  no  reason  to  suppose  that  its  principles  can  be  neg- 
lected without  largely  impairing  the  average  result.  The 
fighting  manual  of  exclusion  may  change  from  year  to  year, 
but  an  uncompromising  hostility  to  germs  will  continue  to 
be  an  abiding  article  of  surgical  faith. 

We  are  now  to  consider  another  point  of  great  importance. 
Fluid  contents  accumulate  in  a  closed  wound.  If  you  re- 
move a  fatty  tumor  from  the  back,  you  will  find  it  difficult 
to  get  a  permanent  union  by  first  intention.  A  sanious  fluid 
collects  beneath  the  uniting  integuments,  and  the  wound 
becomes  an  abscess.  This  often  happens  after  excision  of  the 
breast,  or  of  tumors  under  the  angle  of  the  jaw,  or  beneath 
the  flaps  of  an  amputation.  Ligatures  and  stitches  encourage 
such  abscesses,  and  are  often  responsible  for  them. 

It  is  therefore  a  cardinal  point  in  the  treatment  of  every 
closed  wound  to  evacuate  this  sanious  fluid  by  inserting  in 
the  wound,  before  dressing  it,  a  "tent"  around  which  the 
flaps  may  heal.  Such  a  tent  is  a  small  rubber  tube  perfo- 
rated with  holes,  introduced  at  a  dependent  part  of  the  incis- 
ion, deep  enough  to  insure  drainage.  It  passes  through  the 
oiled  silk  protective,  and  is  then  cut  off  and  secured  by 
a  string,  so  that  it  may  deliver  the  fluids  outside  the  silk 
into  the  muslin.     Every  considerable  sinus  afterwards  occur- 


REPAIR  OF  TISSUE.  337 

ring  about  a  woimd  must  be  thus  drained.  During  the  heal- 
ing of  a  wound  nothing  is  so  insidious  as  the  burrowing  of 
pus,  which  may  occur  even  when  it  is  not  wholly  impris- 
oned. It  travels  by  its  own  weight.  I  have  formerly  and 
repeatedly  impressed  on  you  the  necessity  of  free  incisions 
for  its  evacuation  at  the  nearest  surface  which  it  is  safe 
to  cut.  In  these  days  such  incisions  should  be  tubed,  and 
their  interior  injected  and  carbolized.  If  you  cannot  cover 
them  with  antiseptic  dressing,  let  them  be  carefully  and 
thoroughly  injected  with  a  carbolic  solution  of  one  in  sixty, 
or  one  in  forty,  twice  a  day,  and  placed  under  a  carbolic 
drip. 

The  drainage  tube  is  withdrawn  gradually  and  slowly,  in 
view  of  the  fact  that  any  premature  closing  of  the  interior 
surely  results  in  abscess. 

Horse-hair  and  other  materials  have  been  suggested  as 
substitutes  for  the  rubber  tube,  but  not,  as  I  think,  with 
advantage. 

Although  a  common  silk  ligature,  cut  short  and  left  upon 
an  artery,  after  some  months  decomposes  and  disappears,  cat- 
gut, when  carbolized,  and  whether  employed  as  ligature  or 
stitch,  deliquesces  in  a  few  days,  and  so  repays  the  trouble 
of  its  use.  Once  applied,  it  needs  no  thought,  and  in  fact 
generates  in  its  immediate  neighborhood  a  wholesome  car- 
bolic atmosphere. 

If  you  have  no  atomizer,  drench  a  wound  or  compound 
fracture  inside  and  out  with  a  carbolic  solution  of  one  in 
forty ;  or  wipe  it  out  and  pour  in  carbolized  oil,^  as  originally 
recommended  by  Lister  in  the  treatment  of  compound  frac- 
ture, and  then  get  the  wet  and  ample  dressing  quickly  into 
place,  with  oiled  silk  next  the  wound  ;  or,  if  you  have 
none,  wet  and  carbolized  cotton  batting,  or  folded  cotton 
cloth,    or  both.       A  limb   thus   dressed,    or   even   without 

1  One  part  carbolic  acid  in  six  to  fifteen  parts  of  linseed  oil. 

22 


338  REPAIR  OF  TISSUE. 

dressing,  may  be  placed  under  a  drip,  as  in  the  two  cases  of 
open  knee  joint  in  our  wards,  where  a  wick-yarn  siphon 
leads  the  antiseptic  fluids  to  a  cloth  lightly  laid  on  the 
gaping  wound,  while  another  below  the  limb  conducts  it  from 
a  rubber  sheet  to  the  floor.  On  the  body  a  drip  is  less 
available  than  on  a  limb.  You  may  remember  that  burnt 
flour  is  an  old  and  good  dressing  for  certain  ulcers.  Car- 
bolized  sawdust  or  bran  has  been  advantageously  substituted 
for  flour  upon  a  carbolized  wound. 

Guerin's  cotton  wool  dressing  effectively  filters  the  air, 
especially  if  the  inner  layers  be  wet  and  carbolized.  But 
the  outer  and  dry  layers  should  be  several  inches  in  thick- 
ness, and  largely  overlap  the  wound  or  wrap  the  limb.  The 
surgeon  undoubtedly  obtains  excellent  results  by  Guerin's 
method,  the  carbolic  element,  which  adds  greatly  to  its 
efficiency,  having  been  adopted  from  Lister. 

When  a  large  surface  has  been  dressed  with  a  carbolic 
lotion  for  a  considerable  time,  the  system  may  suffer  from 
its  absorption.  The  most  striking  toxic  indication  is  a 
dark  bluish  green  color  in  the  urine ;  there  is  also  prostra- 
tion. It  is  then  necessary  to  discontinue  the  carbolized 
fluid.     Salicylic  acid  may  be  substituted.  ^ 

I  have  purposely  deferred  until  the  conclusion  of  this 
lecture  two  matters  of  importance.  The  first  is  the  relation 
of  repair  to  the  pulse  and  temperature ;  the  second,  its  rela- 
tion to  coagulum.  The  first  of  these  points  has  great  prac- 
tical interest. 

In  the  old  method  of   dressing  wounds,  hemorrhage  and 

1  Water  dissolves  only  about  one  part  in  three  hundred  of  salicylic 
acid ;  but  the  addition  of  eight  parts  of  borax  to  boiling  water  enables  it 
to  dissolve  ten  parts  in  one  hundred.  Alcohol  dissolves  salicylic  acid, 
and  the  solution  may  be  then  mixed  vrith  vrater  to  impregnate  cotton 
wool.  The  addition  of  a  little  glycerine  keeps  the  pungent  dust  from  the 
atmosphere,  if  the  cotton  be  used  when  dry. 


REPAIR   OF   TISSUE.  339 

suppuration  betrayed  themselves  on  the  surface.  But  you 
will  ask,  as  I  did,  How  can  we  ascertain  whether  a  mass  of 
antiseptic  covering  may  not  imprison  or  conceal  an  abscess 
fatal  to  union,  and  possibly  disastrous  to  the  patient  ?  For- 
tunately, an  abscess  in  the  wound  unfailingly  and  at  once 
reveals  itself  by  an  elevation  of  pulse  and  temperature.  An 
abrupt  ascent  of  the  previous  zigzag  lines  of  a  carefully  kept 
chart  peremptorily  directs  attention  to  the  wound  and  to  a 
renewal  of  the  dressing. 

Such  an  abscess  must  be  at  once  freely  evacuated,  carbol- 
ized,  and  tubed,  whether  it  be  again  protected  by  a  close 
dressing  or  by  a  lighter  antiseptic  covering. 

When  dealing  with  a  wound  which  is  to  be  covered  by 
integument,  the  surgeon  cannot  exercise  too  much  patience 
in  tying  all  the  vessels.  Fluid  may,  notwithstanding  all 
his  care,  collect  in  the  cavity.  The  mere  washing  of  a 
freshly  cut  surface  with  a  carbolic  solution  of  one  in  forty 
excites  the  capillaries  so  that  effectual  drainage  becomes 
essential.  In  a  closed  wound  we  aim  by  the  careful  drain- 
age of  blood  and  serum  to  secure  a  permanent  contact  of  the 
surfaces.  But  in  an  open  wound  a  coagulum  may  be  turned 
to  good  account.  Its  exact  behavior  is  less  important. 
Physiologists  incline  to  the  opinion  that  it  does  not  itself 
become  transformed,  but  that  new  tissue  penetrates  into  its 
interstices.  It  may  thus  become  an  admirable  dressing, 
provided  only  we  prevent  its  death  and  deliquescence.  This 
is  quite  possible  by  thorough  antiseptic  protection. 


340  REPAIR  OF  TISSUE. 


THE   MODERN  ART   OF   PROMOTING   THE    REPAIR 
OF  TISSUE.  1 

There  can  be  no  doubt  that  antiseptic  dressing  is  attended 
with  a  largely  diminished  mortality  in  any  hundred  consec- 
utive surgical  cases,  whether  in  a  hospital  or  elsewhere. 
The  experience  of  surgeons  has  further  confirmed  the  doc- 
trines of  Lister,  and,  if  it  has  not  added  much  to  the  art  of 
antiseptic  treatment,  has  shown  better  what  is  essential  in 
the  method,  and  how  to  secure  it.  Indeed,  the  theory  is  so 
convincing,  its  principles  are  so  few  and  their  application 
so  easy,  that  repair  might  seem  to  be  absolutely  within  the 
control  of  the  surgeon. 

But  this  is  not  the  fact.  Practice  shows  that  wounds  will 
not  always  do  well.  The  surgeon  fails  less  often  perhaps  in 
engineering  a  difficult  case  than  in  adapting  to  a  common 
one  some  simple  detail  connected  with  drainage,  stitches,  the 
ligature  of  arteries,  the  opening  of  a  sinus,  or  other  matter 
of  routine ;  the  problem  being  as  simple  as  a  sum  in  addi- 
tion, but  as  easilv  and  fatally  deranged.  It  is  still  inevi- 
table that  the  results  of  Listerism,  in  spite  of  precaution, 
should  be  sometimes  unsatisfactory. 

Surgeons  still  rely  mainly  on  carbolic  acid.  A  year  ago 
(1876-77)  you  saw  thymol  used  in  my  surgical  wards  with 
excellent  results.  As  less  irritating  to  the  hands,  and  of  a 
more  agreeable  odor,  it  may  be  used  advantageously  in  spray, 
but  in  the  regular  dressing  I  employ  carbolic  acid,  and  resort 
^  Second  Lecture,  delivered  in  1878.     Xoav  first  published- 


REPAIR  OF  TISSUE.  341 

to  thymol  and  salicylic  acid  only  as  substitutes  when  toxic 
symptoms  compel  its  discontinuance. 

A  careful,  persevering  attention  to  drainage,  as  demon- 
strated by  Lister  in  England  and  Chassaignac  in  France, 
which  may  be  practically  included  in  the  antiseptic  method 
because  it  removes  what  most  readily  decomposes,  cannot  be 
too  strongly  enjoined.  We  can  dispense  with  neither,  but 
if  compelled  to  relinquish  one,  I  should  hesitate  between 
drainage  and  antiseptics. 

Nine  times  in  ten  a  closed  wound  heals  outside  before  it 
heals  inside;  the  integuments  unite  before  the  flesh,  and 
then  fluid  may  collect  in  the  cavity,  —  whether  blood  from 
an  untied  artery,  oozing  from  capillaries,  or  exuded  lymph. 
This  fluid,  if  imprisoned,  is  very  fatal  to  union,  converting 
the  wound  into  an  abscess,  and  then  involving  the  gradual 
ulceration  of  the  freshly  united  edges.  If  a  thigh  is  ampu- 
tated for  disease  of  the  knee,  perhaps  a  little  pus  has  previ- 
ously perforated  the  capsule  and  escaped  among  the  muscles 
of  the  thigh  into  a  cavity  barely  admitting  the  finger.  So 
surely  as  the  top  of  this  little  sinus  is  shut  off  and  left  in  the 
stump  undrained,  and  the  integuments  are  brought  closely 
together,  so  surely  will  the  sinus  become  a  formidable  ab- 
scess, rapidly  disintegrating  the  tissues  high  up,  and  even 
endangering  the  life  of  the  patient.  So  an  effort  to  save  a 
crushed  ankle  joint  or  compound  fracture  of  the  leg  often 
begets  insidious  intermuscular  sinuses.  The  burrowing  of 
pus,  whether  among  the  muscles  or  through  freshly  united 
integument,  is  the  arch  enemy  of  operative  and  traumatic 
surgery.  Against  it  the  surgeon  has  one  efficient  resource, 
which  is  to  provide  the  cavity  with  a  tent  or  tube  to  drain 
it,  as  a  sewer  does  a  cesspool. 

Drainage  is  an  art  to  be  learned ;  and  without  some 
disastrous  experiences  you  will  hardly  realize  the  nature  of 
the  accidents  it  is  intended  to  avert.     So  important  is  the 


342  REPAIR  OF  TISSUE. 

evacuation  of  decomposable  fluid  that  Koeberle  and  Keith  do 
not  hesitate  to  evacuate  collected  fluid  by  means  of  a  glass 
tube  introduced  into  the  depths  of.  the  pelvis  during  a  con- 
valescence from  ovariotomy,  if  the  temperature  indicates 
mischief.  But  a  difficulty  incident  to  the  classical  Lister 
dressing  is  that,  when  the  presence  of  an  abscess  is  indicated 
by  the  chart  of  temperature,  the  mischief  has  been  already 
done,  the  pus  has  already  collected,  and  the  cicatrix  has 
begun  to  yield. 

You  will  naturally  inquire  whether  the  antiseptic  treatment 
is  never  compatible  with  a  daily  inspection  of  the  wound 
and  with  a  lighter  dressing.  In  July  of  this  year  I  was 
much  struck  with  cases  in  Mr.  Callender's  wards  at  Saint 
Bartholomew's.  In  addition  to  draining  and  uniting  a  wound 
in  the  usual  manner,  this  surgeon  paints  its  interior  with  a 
large  soft  brush  and  carbolized  oil ;  covers  it  with  a  strip  of 
lint  soaked  in  the  same  fluid,  with  a  second  larger  strip  simi- 
larly oiled,  and,  lastly,  with  gutta-percha  tissue,  all  of  which 
are  kept  in  place  by  a  light  bandage.  The  daily  dressing  con- 
sists in  the  removal  and  renewal  of  the  outer  lint  alone,  the 
inner  layer  being  carefully  left  in  place,  and  only  freshly 
painted.  A  wad  of  charpie  at  the  orifice  of  the  drainage  tube 
is  also  carefully  replaced.  The  use  of  carbolic  oil  is  not 
new;  it  was  largely  employed  by  Lister  in  his  earliest  experi- 
ments, and  this  dressing,  which  is  both  rapid  and  painless,  is 
capable  of  accomplishing  remarkable  results.  I  saw  in  Mr. 
Callender's  wards  two  cases  in  which  the  internal  condyle 
of  the  knee  had  been  detached  by  a  narrow  saw  introduced 
from  above  (the  operation  of  Armadale,  Ogston,  and  Almy). 
What  became  of  the  sawdust  and  blood  effused  in  the  joint 
I  do  not  know.  But  the  cases  were  in  full  tide  of  recovery, 
with  only  the  dressing  I  have  described;  and  although  I 
still  feel  that  so  simple  an  additional  guaranty  of  immunity 
should  not  be  omitted,  T  confess  they  have  somewhat  shaken 


REPAIR  OF  TISSUE.  343 

my  previous  creed  respecting  the  use  of  spray  in  such  opera- 
tions on  the  knee  joint.  I  may  mention,  incidentally,  that 
Mr.  Callender  employs  in  amputation  a  suspended  hinged 
splint,  by  dropping  the  front  of  which  the  stump  is  exposed, 
and  dressed  in  the  way  I  have  described  with  little  or  no  pain. 
But  let  me  call  your  attention  to  a  still  more  striking 
class  of  cases  in  the  practice  of  Koeberle  of  Strasburg.  This 
distinguished  operator,  well  known  for  his  success  in  ovari- 
otomy, uses  neither  carbolic  acid,  nor  other  antiseptic,  rely- 
ing mainly  on  excessive  cleanliness.^  I  was  anew  reminded 
of  the  extent  to  which  success  in  operative  surgery,  literally 
"the  work  of  the  hand,"  may  sometimes  depend  upon  the 
frequent  examination  of  the  progress  of  repair.  In  the 
service  of  Koeberle,  wounds  are  uncovered  twice  a  day  by 
the  surgeon  himself.  During  the  operation,  dry  clean  towels 
in  great  abundance  are  used  as  substitutes  for  sponges ;  the 
lips  of  the  wound  are  approximated  with  great  accuracy,  and 
united  by  sutures  less  than  half  an  inch  apart,  as  well  as 
by  another  expedient  to  be  described  later;  and  the  drainage 
tube  is  of  glass.  Charpie  is  loosely  heaped  along  the  line 
of  union,  and  covered,  not  with  a  bandage,  but  with  a  single 
band  or  belt,  which  can  be  at  once  opened  by  removing 
pins.  Twice  a  day  this  band  is  unfastened,  the  charpie 
removed,  and  every  particle  of  moisture,  every  speck  of 
discolored  blood,  wiped  from  the  surface  and  interstices,  as 
well  as  from  the  orifice  of  the  drainage  tube,  with  bits  of  dry 
charpie.  Here,  without  antiseptics,  but  with  excessive  clean- 
liness, is  the  personal  exercise  of  great  surgical  tact  and 
practical  skill,  insuring  the  earliest  attention  to  emergen- 
cies and  their  prevention;  in  short,  the  active  supervision 
and  guidance  of  repair  as  if  it  were  a  chemical  experiment, 
and  not  a  growth  under  the  ground,  to  be  looked  after  at  a 
certain  interval. 

*  It  is  stated  that  Koeberle  has  since  employed  carbolic  acid. 


344  REPAIR  OF  TISSUE. 

The  exercise  of  sucli  elaborate  care  and  skill  is  wholly 
incompatible  with  the  exigencies  of  a  large  practice,  or  the 
possibilities  of  a  hospital  where  house  officers  are  generally 
overworked,  and  come  to  learn  rather  than  to  lend  a  matured 
judgment  and  experience ;  but  contrasted  with  the  routine 
dressings  of  common  hospital  wards,  or  even  with  a  routine 
antiseptic  dressing,  it  furnishes  matter  for  profitable  study. 
I  believe  that  each  of  these  systems  will  some  day  gain  a 
substantial  advantage  by  the  adoption  of  something  from 
the  other. 

Let  us  now  revert  for  a  moment  to  theoretical  considera- 
tions. I  have  formed  no  opinion  upon  the  relation  of  bac- 
teria, whether  specific  or  not,  to  septicemia,  to  pyemia,  or  to 
so  called  blood  poisoning.  They  are  sometimes,  like  erysip- 
elas, quite  prevalent  in  the  wards,  and  sometimes  absent  for 
months  or  years.  Their  existence  has  by  no  means  an  exclu- 
sive connection  with  lack  of  cleanliness.  You  cannot  produce 
abscesses  in  the  joints,  nor  inflammatory  spots  in  the  lungs, 
by  allowing  a  wound  to  become  surrounded  by  maggots,  for  ex- 
ample. On  the  other  hand,  patients  with  every  care,  healthy, 
and  with  no  clear  provocation,  are  attacked  with  pyemia. 

All  this  will  perhaps  be  understood  at  no  distant  period, 
and  in  the  mean  time  I  prefer  to  suspend  judgment.  But 
with  the  bacterium  present  in  decomposition  the  evidence  is 
more  complete,  and  certainly  leads  us  to  think  that  Pasteur 
may  have  here  identified  the  proximate  mechanism  of  the 
process.  It  plays  a  most  important  part  in  nature.  Just  as 
the  vital  spark  endows  the  elementary  ammonia  with  new  ca- 
pabilities in  the  form  of  protoplasm,  so  when  vitality,  under 
any  name,  leaves  the  plant  or  animal,  it  is  the  duty  of  this 
bacterium  to  decompose  the  protoplasm  into  its  integral  am- 
monia, and  the  whole  material  world  is  thus  at  last  reduced 
into  atoms  by  the  agency  of  this  organism,  which  seems  to 


REPAIR  OF  TISSUE  345 

be  always  contending  with  vitality  for  the  possession  of  the 
living  cell,  and  which,  as  an  uncompromising  enemy  of  livino- 
things,  is  a  more  suggestive  emblem  of  mortality  than  Time 
with  his  scythe.  Minuter  than  the  infusoria  of  the  ocean, 
its  labor  evolves  products  more  vast  than  the  limestone  rocks 
built  out  of  the  remains  of  those  microscopic  animalcule. 
It  is  the  province  of  the  surgeon  to  contend  against  this  in- 
sidious and  omnipotent  foe.  The  thesis  that  now  only  waits 
for  complete  confirmation  is,  that  where  there  is  a  fair  re- 
parative power  wounds  will  always  and  inevitably  heal  in 
the  shortest  time  and  in  the  most  favorable  manner  when  the 
bacteria  of  decomposition  are  absolutely  excluded. 

We  must  look  to  the  laboratory  for  the  crucial  experiments 
relating  to  the  action  of  bacterial  germs  upon  organized 
fluids  which  shall  show  us  how  best  to  effect  their  exclusion. 
It  is  there  recognized,  I  believe,  that  germs  adhering  to 
natural  objects  are  a  more  important  factor  in  experiments, 
and  require  greater  precautions  for  their  extinction,  than 
those  which  are  usually  floating  in  the  air.  In  other  words, 
that  while  atmospheric  germs  are  so  few  and  far  between  as 
to  justify  the  surgeon  in  taking  an  inconsiderable  risk  in 
respect  to  them,  they  are  liable  to  accumulate  in  surface 
dust  and  dirt  to  a  degree  that  makes  it  peremptory  to  destroy 
them.  If  this  be  true,  the  success  of  the  antiseptic  prac- 
tice, already  quoted,  of  Callender  and  Koeberl^,  is  partially 
explained.  It  depends  largely  upon  absolute  local  cleanli- 
ness, and  the  practical  extinction  of  germs  upon  the  part 
itself  during  and  after  an  operation  by  a  machinery  which 
does  not  interfere  with  cell  growth,  as  did  the  soap  and  water 
of  a  conventional  but  less  efficient  procedure.  It  also  points 
to  a  similar  cleanliness  of  the  surgeon's  hands,  operating 
coat,  instruments,  and  sponges. 

A  few  experiments  upon  meat  will  satisfy  the  observer  that 
is  it  difficult  to  determine  exactly  what  should  be  the  strength 


346  REPAIR  OF  TISSUE. 

of  an  antiseptic  solution,  because,  although  certain  bacteria 
can  be  identified  and  killed  under  the  microscope,  yet  a  germ 
is  more  tenacious  of  life.  It  is  less  easily  distinguished 
from  the  surrounding  molecular  matter,  and  in  fact  can  only 
be  distinctly  identified  by  its  power  to  contaminate  other 
fluids.  Upon  this  question  which  relates  to  the  efficiency  of 
antiseptic  solutions  we  must  be  satisfied  with  approximative 
evidence.  Indeed,  this  question  has  not  been  practically 
solved  by  Lister,  nor  can  any  exact  rule  be  laid  down  for 
the  selection  of  an  antiseptic  dressing. 

Something  may  be  predicated  upon  the  shape  of  the  wound, 
and  something  upon  its  locality.  If,  as  in  the  excision  of 
a  knee  joint,  the  subsequent  adjustment  of  the  parts  requires 
time,  and  especially  if,  as  there,  the  wound  itself  is  so 
devious  that,  after  a  protracted  exposure  to  the  atmosphere, 
we  cannot  be  sure  that  every  crevice  is  searched  by  a  final 
antiseptic  washing,  then  it  is  better  to  use  the  preventive 
spray  throughout  the  operation,  and  to  finish  with  a  com- 
plete Lister  dressing.  This  is  the  more  true  if  such  a 
dressing  can  be  readily  applied,  as  around  a  limb  or  stump. 
So  in  the  operation  of  ovariotomy  the  abdominal  cavity  is  a 
series  of  deep  interstices  to  which  antiseptic  prevention  by 
spray  is  eminently  adapted.  The  surface  of  the  trunk  also 
can  be  readily  invested  afterwards  with  gauze  and  cotton. 
In  one  case,  which  in  the  end  proved  successful,  where  the 
adhesions  were  all  but  universal,  and  the  oozing  had  been 
considerable,  I  was  unwilling  to  rely  on  spray  alone,  and 
filled  the  abdominal  cavity  just  before  closing  it  with  a  warm 
carbolic  solution  of  one  in  eighty,  and  then  turned  the  patient 
over  to  drain  it  thoroughly. 

If  the  wound  is  flat  or  superficial,  and  can  be  thoroughly 
washed  a  second  or  two  before  applying  a  dressing,  then  I 
believe  spray  to  be  less  necessary.  In  a  smaller  wound  also 
a  light  antiseptic  dressing,  like  that  of  Callender,  may  prove 


REPAIR  OF   TISSUE.  347 

eflficient.  Upon  a  breast  it  has  the  advantages  of  being  easier 
to  apply,  and  more  comfortable  to  the  patient.  A  greater 
accessibility  of  the  wound  enables  the  surgeon  to  examine 
it  oftener,  and  to  meet  emergencies  earlier ;  in  short,  some- 
times to  preserve  union  when  endangered  by  abscess  and 
ulceration. 

If  the  great  aim  of  the  new  method  is  the  healing  of 
wounds,  we  may  perhaps  advantageously  review  some  of  the 
other  expedients  contributory  to  the  success  of  antiseptics 
and  efficient  drainage,  and  which  in  combination  with  these 
subserve  what  I  have  called  the  modern  art  of  promoting 
repair  of  tissue. 

Before  operation  the  integuments  should  be  shaved  and 
thoroughly  washed  with  a  carbolic  solution. 

Incisions  should  be  calculated  with  reference  to  a  subse- 
quent comfortable  position  for  the  patient  in  bed,  so  that 
the  place  of  the  drainage  tube  shall  be  habitually  a  de- 
pending one. 

Leaking  of  the  wound  should  be  prevented  by  every  possi- 
ble expedient ;  in  amputation,  for  example,  by  clean  contin- 
uous cuts,  avoiding  small  muscular  incisions  in  the  depths  of 
which  oozing  may  occur.  Every  vessel  should  be  sedulously 
secured.  Large  catgut  is  liable  to  slip  off;  small  catgut  may 
deliquesce  too  soon ;  so  that  while  the  unimportant  vessels 
are  tied  with  the  finer  gut,  and  the  principal  artery  with  a 
larger  size,  the  latter  may  be  reinforced  for  security  with 
a  ligature  of  sewing-silk  cut  off  short  and  left  for  absorp- 
tion. It  would  be  wise  if  every  wound  were  kept  open  a 
quarter  or  half  an  hour  under  antiseptic  protection,  or  even 
otherwise  until  dry.  I  should  not  omit  to  mention  the 
expedient  originating  with  Koeberl^,  though  since  claimed 
by  others,  of  compressing  the  smaller  vessels,  as  fast  as  they 
are  cut,  with  forceps  left  hanging  from  the  wound,  a  dozen  or 


348  REPAIR  OF  TISSUE. 

more  perhaps,  until  the  end  of  the  operation,  after  which  it 
will  be  found  that  few  of  the  smaller  vessels  require  tying. 

Another  useful  expedient  in  the  practice  of  the  same 
surgeon  is  that  of  packing  a  number  of  dry  towels  in  contact 
with  the  oozing  vessels  of  the  peritoneum  and  intestines  for 
a  few  minutes  during  or  after  ovariotomy.  A  dry  cloth  in 
any  fresh  wound  similarly  arrests  oozing.  So  does  the 
application  of  hot  water.  It  is  better  to  lay  the  drainage 
tube  in  the  wound  before  closing  it,  than  to  thrust  it  into  a 
hole  afterwards,  at  the  risk  of  displacing  a  ligature. 

In  operations  upon  the  limbs,  subsequent  muscular  rest 
should  be  secured  by  splints  if  necessary. 

In  approximating  flaps  two  distinct  points  deserve  con- 
sideration, their  traction  and  their  apposition.  It  is  not 
safe  always  to  rely  on  stitches  to  accomplish  both  objects. 
When  these  ulcerate  and  require  removal,  the  union  may  not 
be  firm  enough  to  resist  the  tension  of  the  flaps,  which  need 
support  until  united.  Such  support  may  be  afforded  in  well 
known  ways,  as  by  an  occasional  wire  suture  an  inch  from 
the  margin.  Koeberle  uses  with  excellent  effect  loose  cotton 
thread  or  "  waste  "  between  each  stitch  or  two,  spread  out 
like  a  fan  on  either  side  and  attached  to  the  skin  by  collo- 
dion. Similarly  I  have  used  dentists'  floss  silk.  In  the 
large  flaps  of  a  breast  or  of  an  amputation,  wires  with  shields 
and  shot  answer  well ;  but  thick  flaps  are  liable  to  swell,  as 
in  a  stump  or  in  the  perineum,  and  it  will  be  essential  to 
relax  the  wire  after  a  day  or  two,  for  which  purpose  I  have 
used  a  sliding  screw  clamp  as  a  substitute  for  shot. 

Ulcerating  stitches  rapidly  and  largely  disorganize  a  new 
cicatrix.  It  is  therefore  better  to  remove  them  by  the  third 
day.  But  under  an  antiseptic  dressing  they  may  often  remain 
a  week,  and  under  collodion  still  longer.  A  wire  suture,  such 
as  I  have  spoken  of,  supported  by  a  shield  beneath  which 
some  lint  is  placed,  and  daily  touched  with  a  brush  dipped 


REPAIR  OF   TISSUE.  349 

in  carbolic  oil,  sometimes  does  not  cut  through  the  skin  for 
weeks.  Catgut  stitches  deliquesce  beneath  collodion,  and  if 
reinforced  by  floss  silk  tractors  need  not  be  removed  at  all. 

The  traction  and  the  apposition  of  flaps  are  separate  func- 
tions, and  as  traction  upon  stitches  promotes  their  ulcera- 
tion they  may  be  antagonistic,  and  obviously  require  distinct 
appliances. 

While  a  redundant  flap  is  far  better  than  a  scanty  one,  a 
wound  is  easier  to  dress,  especially  by  the  open  antiseptic 
method,  if  the  integuments  are  flat,  than  if  they  are  raised 
or  corrugated,  to  which  end  they  should  be  carefully  cut  and 
fitted  so  as  to  permit  the  lint  dressing  to  lie  smoothly.  I 
cannot  but  think  that  for  a  breast,  at  least,  Callender's 
method  is  best.  If  it  is  adopted  for  amputation,  the  corners 
of  a  circular  flap  should  be  trimmed  when  brought  together, 
in  order  to  round  the  end  of  the  stump. 

In  dressing  a  wound,  the  cavity  of  which  has  suppurated, 
it  should  be  thoroughly  syringed  with  the  carbolic  or  thymol 
solution  and  drained  by  a  tube,  and  any  uniting  part  care- 
fully supported. 

But  in  spite  of  all  precautions  the  surgeon  will  be  occa- 
sionally doomed  to  disappointment  by  the  grandest  ulcera- 
tive destruction  of  an  extended  union  by  first  intention.  It 
usually  begins  near  the  orifice  of  the  drainage  tube.  I  have 
had  little  success  in  arresting  its  progress,  and  am  dis- 
posed to  adopt,  in  dressing  this  part  of  the  wound,  the  most 
rigorous  antiseptic  measures  of  prevention. 

Except  in  a  complete  Lister  dressing  much  is  added  to 
the  comfort  of  surgeon  and  patient  by  substituting  for  the 
usual  bandage  a  wide  swathe,  previously  fitted  to  the  part  and 
brought  together  by  pins  or  tapes  so  that  it  can  be  opened 
like  a  folding  door,  disclosing  the  mass  of  clean  charpie 
under  which  is  the  lint  or  protective  which  lies  in  contact 
with  the  wound. 


350  REPAIR  OF  TISSUE. 

Before  applying  such  a  band  or  bandage,  the  oiled  lint  or 
protective  over  cavities  and  hollow  curves  should  be  padded 
by  a  mass  of  charpie,  loosely  thrown  here  and  there,  to  secure 
Ijy  its  distribution  a  uniform  and  elastic  pressure  in  bringing 
together  the  walls  of  the  wound  and  effectually  excluding 
obnoxious  agencies. 

Such  are  some  of  the  minor  expedients  the  adroit  use  of 
which  characterizes  the  skilful  surgeon.  It  is  no  exagger- 
ation to  speak  of  them  as  the  pawns  whose  judicious  or 
unskilful  work,  after  a  severe  operation,  may  easily  decide 
the  game  of  life  and  death.  If  through  the  agency  of  antisep- 
tic influences,  aided  by  these  expedients,  all  wounds  could 
be  made  to  unite  as  the  healthiest  do,  and  to  fill  up  as  rapidly 
and  completely  as  now  and  then  happens,  the  surgical  wards 
of  hospitals  would  offer  a  different  aspect,  and  require  less 
care  than  at  present.  In  the  mean  time  let  us  thank  Mr. 
Lister  for  the  great  advance  surgery  has  lately  made  in  this 
direction. 


CURE  OF   UMBILICAL  HERNLA..  351 


KADICAL  CURE,  WITHOUT  OPERATION,  OF  A  LAEGE 
UMBILICAL   HERNIA.^ 

Mrs.  B.,  Irish,  thirty-two  years  of  age,  strong  and  healthy, 
weighs  two  hundred  and  thirty  pounds.  Seven  years  ago, 
after  a  third  confinement,  she  discovered  a  slight  hernia  at 
the  umbilicus,  which  increased  in  size  until  it  became  neces- 
sary to  wear  a  binder  to  keep  the  protrusion  in  place. 
During  warm  weather  the  patient  was  in  the  habit  of  throw- 
ing off  this  binder,  and  there  followed  a  constant  increase  in 
the  size  of  the  protuberance.  Two  weeks  before  her  ad- 
mission to  the  hospital  it  became  painful,  and  its  under  side 
ulcerated  from  chafing. 

November  4,  1880.  On  admission  the  hernia  was  of  the 
size  of  a  child's  head,  and  its  whole  mass  was  red  and 
inflamed.  Manipulation  caused  nausea.  There  had  been 
vomiting  for  five  days  before  entrance,  and  no  movement  of 
the  bowels  for  three  days.  After  etherization  only  a  small 
portion  of  the  tumor  could  be  reduced.  The  remaining  part, 
which  hung  down  toward  the  pubes,  was  then  supported  by 
charpie  placed  beneath  it,  and  compressed  and  held  in  posi- 
tion by  adhesive  plaster.  A  poultice  was  applied  over  all. 
Temperature  102°  F. 

November  8.  The  hernia  was  again  in  part  reduced,  caus- 
ing a  slight  amount  of  pain,  and  the  strapping  with  adhesive 
plaster  was  renewed.  The  tumor  was  now  about  the  size  of 
a  large  apple.  The  bowels  were  spontaneously  moved  at  this 
time,  seven  days  after  the  first  symptoms  of  strangulation. 
Temperature  normal. 

1  Boston  Medical  and  Surgical  Journal,  January  5,  1882. 


352  CURE   OF   UMBILICAL   HERNIA. 

November  14.  Pressure  was  applied  upon  the  mass  of  skin 
and  its  contents  by  means  of  a  large  cork  with  a  convex  sur- 
face, held  firmly  in  place  by  adhesive  plaster  and  a  swathe. 

November  21.  The  integument  of  the  sac  was  puckered. 
It  was  of  a  dark  color,  but  there  was  no  tenderness  or  lack 
of  sensation.  The  discoloration  was  probably  due  to  ecchy- 
mosis  from  tight  strapping.  Examination  revealed  two  dis- 
tinct rings,  —  a  large  one  in  the  place  of  the  umbilicus,  at 
its  side  a  smaller  one,  which  appeared  to  be  directed  toward 
the  larger  ring. 

November  29.  (Twenty-five  days  after  entrance.)  The 
sac  has  become  invaginated,  and  the  depression  which  occu- 
pies its  place  will  hold  an  ounce  and  a  half  of  water.  The 
larger  ring  readily  admits  the  forefinger.  There  is  some 
tenderness. 

December  2.  Tincture  of  cantharides  was  injected  into 
the  cavity  formed  by  the  invagination  of  the  sac,  in  order  to 
blister  its  surface  and  cause  adhesion. 

December  18.  Liquor  ammonise  (fort.)  was  injected  and 
allowed  to  remain  for  several  minutes. 

December  26.  Tincture  of  iodine  (one  part  to  eight  of 
water)  was  injected. 

January  3.  The  sac  has  lost  its  former  tendency  to  pro- 
trude when  the  pad  is  removed. 

January  21.  Considerable  suppuration  from  the  invagi- 
nated surfaces,  and  much  pain. 

February  8.  Liquor  ammonias  (fort. )  again  injected.  The 
invaginated  surfaces  of  integument  appear  to  be  growing 
together. 

March  1.  (One  hundred  and  sixteen  days  after  entrance. ) 
Granulations  are  seen  at  the  neck  of  the  inverted  sac. 

March  19.     Liquor  ammoniae  (fort. )  injected. 

April  13.  Interior  of  the  inversion  touched  with  nitrate 
of  silver.     A  sinus  still  admits  a  probe. 


CURE   OF  UMBILICAL    HERNIA.  353 

May  15.  A  large,  tight-fitting  truss  was  applied  over  the 
ring. 

May  25.  (Two  hundred  and  two  days  after  entrance.) 
The  patient  sits  up  for  a  short  time.  There  is  no  tendency 
in  the  hernia  to  protrude.  The  cavity  formed  by  the  invagi- 
nation of  the  sac  is  entirely  obliterated. 

June  1.     The  patient  walks  about  the  ward. 

June  6.  (Two  hundred  and  fourteen  days  after  entrance. ) 
Discharged  well,  although  directed  to  wear  a  truss  at  present 
as  a  matter  of  precaution.  The  obliterated  sac  has  evidently 
formed  a  pad  upon  the  inside  of  the  abdominal  wall  which 
occludes  the  umbilical  ring. 


23 


354  FEES  IN  HOSPITALS. 


FEES   IN   HOSPITALS.  1 

Whatever  a  medical  officer  may  think  of  the  right  to 
receive  fees  from  patients  for  services  rendered  within  the 
walls  of  a  charity  hospital,  there  is  no  doubt  that  its  practice 
would  be  detrimental  to  the  institution.  The  writer  de- 
sires to  place  permanently  on  record  a  few  of  the  hitherto 
unwritten  arguments  against  such  fees. 

The  excellent  general  management  of  some  of  the  American 
hospitals  is  well  known.  Their  exceptional  comfort,  their 
careful  nursing,  and  their  elaborate  equipment  attract  to 
them  persons  of  a  higher  class  than  are  generally  met  in  such 
institutions  abroad ;  among  them  patients,  no  matter  what 
may  be  their  disease,  who  are  able  to  command  all  that  is 
essential  to  their  personal  comfort  and  proper  treatment 
elsewhere.  Indeed,  the  question  has  been  raised  whether 
some  of  the  American  hospitals  are  not  more  elaborate  than 
the  friends  of  the  poor,  by  whom  they  were  established  and 
are  kept  up,  will  permanently  support.  But  there  is  another 
point  which  it  is  the  object  of  this  comunication  briefly  to 
discuss.  In  satisfying,  by  a  certain  luxury  of  accommoda- 
tion not  inexpensive  to  maintain,  a  class  of  patients  who 
are  able  to  pay  their  physicians,  there  is  always  the  danger 
that  such  a  hospital  may  drift  from  its  original  purpose, 
and  become  more  or  less  a  maison  de  santS,  the  first  object 
of  which  is  not  so  much  the  relief  of  the  poor  as  the  emolu- 
ment of  the  practitioner.  Medical  men,  notably  specialists, 
often  establish  for  their  private  patients  very  successful 
maisons  de  sante,  but  it  is  perhaps  well  to  inquire  how  far 

1  Boston  Medical  and  Surgical  Journal,  April  18,  1889. 


FEES   IN   HOSPITALS.  855 

what  is  advantageous  to  private  interests  may  be  disadvan- 
tageous to  a  large  public  charity. 

The  question  of  fees  is  not  a  new  one,  nor  is  it  confined 
to  Boston  hospitals.  In  this  country  it  is  not  uncommon  to 
hear  a  physician  or  surgeon  express  the  wish  to  be  allowed 
to  receive  money  from  his  hospital  patient,  and  even  his  con- 
viction that,  under  certain  circumstances,  it  is  proper  he 
should ;  and  it  happens  now  and  then  that  a  hospital  patient 
would  prefer  to  remunerate  his  medical  attendant.  But  it  is 
safe  to  say  that  fees,  however  plausibly  advocated,  do  not 
harmonize  with  the  spirit  of  a  public  charity. 

There  are  many  objections  to  such  a  practice.  In  hospi- 
tals where  there  are  patients  by  no  means  destitute,  it  would 
be  difficult  to  restrict  it.  Permission  to  seek  for  a  pecuniary 
remuneration  would  undoubtedly  lead  to  an  effort  to  secure 
it.  And  not  from  the  well-off  alone,  for  it  is  everywhere 
the  willing  patient  that  most  readily  pays  his  physician; 
the  wealthy  patient  is  not  always  liberal,  and  others  may  be 
liberal  beyond  their  means.  Emolument  will  be  obtained 
where  it  is  sought  for.  Should  the  practice  begin  in  the 
private  rooms,  it  would  easily  extend  to  the  wards.  If  the 
collection  of  fees  were  allowed  in  a  special  class  of  diseases, 
it  would  be  leniently  sanctioned  in  other  diseases. 

Nor  could  the  permission  be  confined  to  one  class  of 
officers  without  doing  injustice  to  the  rest.  The  patient,  after 
paying  his  share  of  the  current  expenses  of  the  institution 
and  of  the  interest  on  its  original  cost,  might,  moreover,  be 
asked  to  recompense  not  only  his  medical  attendants,  but 
other  persons.  The  nurses,  for  example,  would  claim  with 
justice  that,  if  any  service  was  to  be  remunerated  by  a 
liberal  patient,  their  faithful  attention  was  deserving  of 
recognition;  or,  at  least,  that  the  training  schools  which 
supply  the  nurses  should  be  remunerated  for  their  outlay. 
The  hard-worked  house  officers  —  who,  except  at  the  daily 


356  FEES  IN  HOSPITALS. 

visit,  have  chief  charge  of  the  patient,  and  who,  especially 
in  the  surgical  service,  largely  relieve  the  visiting  officer  of 
the  onerous  part  of  his  daily  duty,  and  upon  whose  fidelity 
the  patient  is  dependent  for  his  comfort  —  should  certainly 
receive  their  share  of  any  pecuniary  reward.  Indeed,  if  the 
attending  physicians  are  to  be  authorized  to  receive  fees,  why 
should  not  the  officers  of  the  immense  out-patient  depart- 
ment be  permitted  to  enjoy  perquisites  which  now  are  not 
allowed.  A  very  considerable  practice  might  be  established 
among  patients  in  easy  circumstances  attracted  to  that  de- 
partment by  the  reputation  of  the  institution,  who  could  be 
retained  as  their  private  clients,  or  sent  to  their  friends. 
The  highest  resident  officer  of  a  hospital,  to  whom  all  pa- 
tients virtually  apply,  would  also  be  justified  in  treating 
medically,  out  of  the  hospital,  any  or  all  rich  applicants 
whose  condition  did  not  necessitate  admission. 

The  answer  to  these  suggestions  is  that  a  public  hospital 
is  a  trust,  originally  set  apart  as  a  charity  for  the  sick,  and 
not  for  the  pecuniary  benefit  of  their  attendants.  Whatever 
in  a  charitable  institution  is  practised  for  this  end  leads 
to  its  gradual  insidious  deterioration.  Once  allow  fees  and 
perquisites  within  a  hospital,  the  institution  would  be  legiti- 
mately worked  for  all  it  is  worth,  and  patients  who  paid  their 
attendants  would  be  not  the  worst  cared  for. 

In  certain  hospitals  by-laws  distinctly  prohibit  fees;  but 
there  are  cases  which  by-laws  cannot  cover.  Thus,  if  a 
medical  man,  because  he  has  attended  a  well-to-do  patient 
in  a  hospital,  should  charge  him  on  that  account  an  unusual 
sum  for  further  attendance  after  he  has  left  the  hospital,  no 
by-law  can  prevent  such  an  imposition.  The  trustees  should 
make  sure  that  the  patient  while  in  the  hospital  is  so  far 
informed  upon  the  subject  that  he  shall  not  pay  an  excessive 
demand  of  this  sort  through  a  sense  of  supposed  obligation 
incurred. 


FEES  m  HOSPITALS.  357 

Let  us  at  this  point  mention  two  extreme  cases  which  are 
often  urged  by  the  advocates  of  a  fee  system.  The  first  is 
that  of  a  liberal  or  wealthy  person,  who,  having  met  with  a 
serious  accident  at  the  door  of  a  hospital,  and  having  been 
treated  with  skill  and  attention  in  its  private  rooms,  proceeds 
to  pay  his  bill.  After  remunerating  the  institution  perhaps 
doubly,  he  next  desires  to  pay  his  surgeon,  and  unexpectedly 
encounters  a  restrictive  rule,  which  seems  to  be  a  great  hard- 
ship to  both  parties.  One  hospital  at  least  has  provided,  to 
our  knowledge,  a  safety  valve  for  this  rare  emergency.  It 
virtually  says  to  the  patient,  "Such  a  practice  would  not 
conduce  to  the  general  welfare  of  this  institution.  But  we 
shall  be  grateful  to  you  for  a  further  contribution,  and  the 
money  will  be  applied  to  the  cure  of  some  unhappy  sufferer 
we  should  be  otherwise  unable  to  receive."  There  is  no 
injustice  in  such  an  arrangement.  The  medical  officer  is 
fully  compensated  for  his  services  without  receiving  fees. 
The  distinction  of  holding  his  prominent  position  is  well 
understood,  the  world  over,  to  be  ample  remuneration,  both 
indirectly  in  money  and  in  other  ways,  for  any  professional 
service  rendered  by  its  incumbent.  To  be  associated  medi- 
cally, and  especially  surgically,  with  a  hospital  in  high 
repute,  to  share  in  the  experience  it  affords,  to  stand  as  its 
representative  at  once  before  the  medical  world  and  the 
never  ceasing  current  of  patients  who  are  often  attracted 
mainly  by  its  traditional  reputation,  is  to  be  largely  in  debt 
to  it.  It  has  been  said,  with  truth,  that  these  hospital 
offices  would  command  a  considerable  premium  in  money 
from  the  best  class  of  practitioners  were  they  annually  put 
up  at  auction.  If  however  it  should  ever  be  thought  that 
its  medical  officers  were  not  sufficiently  compensated,  it 
would  be  less  objectionable  if  their  claim  should  be  for 
salary  rather  than  for  fees. 

The  other  case,  which  not  unfrequently  occurs,  is  that  of 


358  FEES  IN   HOSPITALS. 

a  physician  or  surgeon  who  advises  one  of  his  patients  to 
enter  the  hospital  with  which  he  is  connected.  The  diffi- 
culty here  is  that  every  person  who  applies  to  a  physician 
for  advice,  whether  recently  or  not,  becomes  technically  his 
patient.  Indeed,  as  happens  daily,  a  person  directed  by  a 
country  practitioner  to  a  medical  officer  of  a  hospital  merely 
to  secure  for  him  the  advantages  of  the  institution  with 
which  he  is  connected  might,  with  customary  propriety,  be 
entered  as  his  particular  patient,  and  on  that  ground  a  fee 
could  be  asked  from  him.  In  short,  a  concession  in  favor 
of  the  physician  of  the  right  to  take  fees  from  his  particu- 
lar patient  could  be  made  to  include  anybody  he  might  place 
in  the  institution. 

It  should  not  be  forgotten  that  the  outside  profession  must 
be  considered.  When  the  advantages  of  a  hospital  intended 
by  the  public  as  a  trust  for  the  poor  are  so  organized  as  to 
divert  patients,  able  to  pay,  from  physicians  who  are  not 
allowed  to  attend  them  therein,  the  outside  profession  have 
a  clear  right  to  be  dissatisfied.  In  fact,  they  are  quite 
alive  upon  this  point,  and  have  repeatedly  expressed  this 
feeling.  The  only  justification  of  a  hospital  would  be  that 
the  money  of  these  patients  went  to  its  funds  in  support  of 
its  charities,  and  not  to  its  medical  officers. 

Another  point,  relating  to  hospital  attendance  by  a  medi- 
cal officer  off  duty,  deserves  to  be  looked  at  carefully.  In 
Boston  a  medical  officer  has  a  permanent  right  to  attend  a 
patient  out  of  his  term  of  service.  In  other  cities  this  right 
is  usually  an  exceptional  courtesy,  temporarily  conceded  by 
the  officer  in  regular  attendance.  Were  it  agreed  that  a  phy- 
sician might  have  patients  in  a  hospital  indefinitely,  a  prac- 
titioner of  business  ability  could  easily  arrange  for  a  perma- 
nent body  of  patients,  drawn  from  a  wide  range  of  country, 
to  be  daily  visited  by  himself  with  great  economy  of  time 
and   trouble,    to  be  supervised   for  his   benefit  by  hospital 


FEES   IN   HOSPITALS.  359 

trustees,  to  be  nursed  by  the  training  school  nurses  and 
by  hospital  employees,  at  a  much  less  expense  than  similar 
care  would  cost  them  outside  the  walls.  Such  an  arrange- 
ment might  enable  the  patient  to  pay  his  medical  attendant 
readily ;  but  this  was  not  contemplated  in  the  trust  instituted 
by  the  founders  of  the  charity.  There  may  be  occasionally 
a  special  reason  for  it,  but  a  recognized  habit  of  attendance 
on  patients  by  medical  officers  out  of  their  term  of  service, 
aside  from  the  inconvenience  it  occasions  to  the  adminis- 
tration, is  a  first  step  towards  changing  part  of  a  hospital 
into  a  maison  de  sante  for  the  benefit  of  the  physicians.  Add 
the  right  to  receive  fees,  and  the  change  is  complete. 

Lastly,  though  not  least  important,  if  a  hospital  is  depend- 
ent upon  legacies  and  charitable  subscriptions,  it  should  be 
able  to  go  to  the  community  with  clean  hands.  No  appeal  in 
its  behalf  would  excite  much  sympathy  were  it  known  that  a 
portion  of  the  money  given  was  to  enable  medical  men  to 
collect  fees  more  conveniently. 

All  this  may  be  briefly  recapitulated.  Whatever  diverts 
the  property,  the  resources,  or  the  conveniences  of  a  charity 
trust,  or  the  patients  who  seek  aid,  to  the  private  advantage 
of  its  officers,  is  a  form  of  the  spoils  system.  If  persons 
abundantly  able  to  pay  are  to  be  from  time  to  time  cared 
for,  —  and  there  may  be  occasions,  especially  in  surgery, 
when  it  is  convenient  to  the  physician  or  better  for  the 
patient,  —  while  the  charges  should  be  such  that  no  mere 
wish  for  economy  would  lead  them  to  a  hospital,  their  money 
should  go  to  the  general  funds,  and  not  to  the  officers.  If 
the  occasion  to  receive  fees  occurs  rarely,  the  emolument 
may  be  easily  foregone,  but  if  it  is  so  frequent  that  the 
right  is  worth  contending  for,  that  fact  is  an  objection 
to  it.  Prevention  is  often  the  least  troublesome  cure; 
it  is  well  to  distrust  any  wedge  which  might  open  the  way 
to  fees. 


360  FEES   IN   HOSPITALS. 

The  trustee  of  a  hospital,  often  a  much  occupied  business 
man,  gratuitously  devotes  ill  spared  time  to  its  service  be- 
cause it  is  a  charity.  The  medical  officer  also  can  afford  to 
be  disinterested ;  he  is  already  sufficiently  benefited  by  his 
position,  and  is  at  liberty  to  resign  it  when  it  is  no  longer 
advantageous  to  him. 

The  views  here  recorded  are  held  by  many  of  the  medical 
officers  of  our  hospitals.  They  have  undoubtedly  contributed 
to  the  welfare  of  the  institutions.  Indeed,  of  one  of  these 
hospitals  it  was  lately  said,  "  Its  traditions  and  its  charities 
are  at  this  moment  as  clean  as  are  its  walls  and  floors. " 


From  Photograph  of  Engraving  in  the  Bihliotheque  Nationals,  Paris. 


From  Photograph  of  Portrait 
Owned  by  the  Boston  Society  for  Medical  Improvement. 


AN  OLD  PORTKAIT  OF  A  SURGEON.         361 


AN  OLD  PORTRAIT  OF  A  SURGEON.i 

It  has  occurred  to  me  that  the  Society  might  like  to  hear 
the  conclusions  I  have  reached  in  an  inquiry  of  no  great  im- 
portance, which,  although  it  was  made  for  my  own  amuse- 
ment, and  has  occupied  more  time  than  I  had  expected, 
relates  to  one  of  our  possessions. 

The  old  portrait  of  a  surgeon  hanging  on  our  walls  and 
familiar  to  members,  was  bought  at  Leonard's  auction  rooms 
about  forty  years  ago.  The  picture  has  a  good  deal  of  merit, 
and  my  own  interest  in  it  lies  in  the  fact  that,  while  bidding 
for  myself,  I  ceded  its  purchase  at  his  request  to  the  late  Mr. 
William  Appleton,  who  soon  afterward  gave  it  to  the  Medical 
Improvement  Society. 

Some  years  ago,  as  a  matter  of  curiosity,  I  tried  to  ascer- 
tain whom  this  picture  was  intended  to  represent,  and  to  do 
so  I  availed  myself  of  the  kind  permission  of  the  Society  to 
have  it  photographed.  This  was  about  a  year  before  I  inci- 
dentally learned  from  our  librarian  that  anybody  else  felt  an 
interest  in  the  subject. 

Why  the  picture  received  the  honored  name  of  Ambroise 
Pare,  which  has  remained  attached  to  it  for  nearly  forty  years, 
I  never  knew.  The  late  Dr.  Bethune  told  me,  at  the  time  of 
its  presentation,  that  the  portrait  resembled  one  of  Ambroise 
Par^  which  was  in  the  folio  copy  of  his  Works  then  belonging 
to  Dr.  Holmes  and  now  in  the  possession  of  this  Society ;  and 

1  Read  before  the  Boston  Society  for  Medical  Improvement,  April  22, 
1889.     Boston  Medical  and  Surgical  Journal,  June  6,  1889. 


362         AN  OLD  PORTRAIT  OF  A  SURGEON. 

the  trephine  which  appears  in  the  picture  is  an  instrument  so 
connected  with  the  name  of  Pare  that  it  seemed  in  some  de- 
gree to  corroborate  this  view ;  although  I  may  observe  that 
the  particular  trephine  here  represented  is  not  furnished  with 
the  safety  guard,  the  chaperon,  devised  by  that  surgeon. 

Further  and  more  recent  consideration  of  the  subject  was 
mainly  that  of  two  points.  First,  the  question  of  resemblance 
or  non-resemblance  of  the  features  in  this  oil  painting  to  those 
of  other  portraits  of  Pare ;  and,  secondly,  the  accessory  evi- 
dence, chief  of  which  is  the  supposed  professorial  robe  in 
which  the  subject  of  our  picture  is  painted. 

In  considering  how  far  the  features  of  the  different  por- 
traits of  Pare  resemble  each  other,  we  are  at  once  struck  with 
the  small  size  of  the  under  jaw.  Hardly  one  man  in  a  hun- 
dred has  as  short  a  jaw  as  is  represented  in  some  of  these 
portraits.  Indeed,  this  abbreviated  jaw  is  a  characteristic  of 
the  most  authentic  portrait  of  Pare. 

Now  the  portrait  belonging  to  the  Society  has  the  same 
short  jaw.  It  is  very  short  indeed ;  a  curious  coincidence, 
which  doubtless  had  its  influence  when  the  name  of  Pare  was 
selected  for  it. 

I  am  indebted  for  the  accessory  evidence  which  I  shall  be 
able  to  give,  to  M.  Le  Paulmier  of  Paris,  the  highest  author- 
ity on  the  subject,  who  has  written  a  most  interesting  and 
well  known  biography,  entitled  "Ambroise  Pare  d'apres  de 
nouveaux  Documents  decouverts  aux  Archives  Nationales,  et 
des  Papiers  de  Famille,  1885,"  and  with  whom  I  have  been  in 
correspondence  for  a  year  or  more. 

In  the  critical  notice  in  his  book  of  the  existing  portraits  of 
Ambroise  Par^,  most  of  which  are  to  be  found  in  the  different 
editions  of  his  Works,  M.  Le  Paulmier  refers  nearly  all  to  a 
common  original,  an  authentic  oil  painting  of  the  great  sur- 
geon at  the  Chateau  de  Paley,  and  more  directly  to  a  well 
known  engraving  of  Delaune,  which  he  considers  to  have  been 


AN  OLD  PORTRAIT  OF  A  SURGEON.         363 

taken  from  that  painting.  In  view  of  this  common  origin,  it 
might  be  supposed,  however  inferior  most  of  them  are  as 
works  of  art,  that  these  various  engravings  would  resemble 
each  other ;  and  yet,  apart  from  the  peculiarity  of  the  jaw 
already  alluded  to,  it  is  not  easy  to  see  at  once  how  they  can 
represent  the  same  individual,  or  even  to  discover  any  resem- 
blance between  some  of  them  but  that  of  a  short  jaw,—  and 
so  far  as  that  goes  the  portrait  of  the  Society  might  be  a 
genuine  one.  The  evidence  from  such  portraits  as  are  ac- 
cessible in  Boston  cannot  be  said  to  be  conclusive.  But  some 
of  them  are  upon  the  table,  and  gentlemen  can  form  their  own 
opinion  about  this. 

Next,  as  the  Society  will  remember,  came  the  additional 
evidence  of  a  superb  portrait  by  Porbus,  said  to  be  of  Am- 
broise  Pare,  representing  a  man  of  noble  mien  and  fine  ex- 
pression, a  photograph  of  which  the  Society  owns.  If  this 
portrait  were  authentic,  the  Society's  portrait  could  by  no 
reasonable  probability  be  supposed  to  represent  Ambroise 
Par^,  and  to  my  own  mind  this  new  evidence  seemed  quite 
conclusive. 

Unfortunately,  on  further  inquiry,  this  fine  picture  attrib- 
uted to  Porbus  turns  out  to  be  a  portrait  of  another  person. 
M.  Le  Paulmier  says  {op.  cit.,  page  134):  "Some  galleries 
possess  pretended  portraits  of  the  illustrious  Pare  which  rep- 
resent wholly  different  individuals.  I  will  only  cite  two,  one 
which  is  in  the  Chateau  d'Azay-le-Rideau,  bearing  the  modern 
inscription, '  Ambroise  Pare,  born  in  1517,  surgeon  of  King 
Henry  HI.';  and  another,  a  magnificent  portrait  belonging 
to  Madame  N^laton,  which  figured  at  the  late  exposition  of 
the  Trocadero.  This  last  is  attributed  to  Pieter  Porbus,  and 
represents  an  unknown  person."  We  must  therefore  leave 
this  portrait  out  of  the  question. 

In  regard  to  the  second  point,  —  the  supposed  professorial 
robe  or  gown,  —  the  question  has  been  raised  here  whether 


364         AN   OLD  PORTRAIT  OF  A  SURGEON. 

Ambroise  Pare  had  the  right  to  wear  this  robe.  It  was 
justly  said,  that,  if  he  were  not  entitled  to  it,  the  presence 
of  the  robe  in  the  picture  would  tend  to  show  that  this  is  not 
a  portrait  of  Ambroise  Pare. 

Bnt,  on  the  other  hand,  if  Ambroise  Pare  did  possess  the 
right  to  wear  a  robe,  this  argument  is  without  weight,  and 
we  are  left  as  much  in  the  dark  as  before.  I  shall  soon  show 
that  Ambroise  Pare  was  entitled  to  wear  one. 

It  is,  however,  possible  to  throw  light  on  the  whole  ques- 
tion. 1  can  at  last  fortunately  present  evidence  of  a  conclu- 
sive nature  that  the  portrait  of  the  Society  is  not  that  of 
Ambroise  Pare,  by  showing  whose  it  really  is. 

I  sent  a  photograph  of  our  portrait  to  M.  Le  Paulmier,  and, 
after  a  somewhat  troublesome  research,  he  was  able  to  iden- 
tify it.  It  represents  Frangois  Herard,  a  French  surgeon  of 
eminence  who  died  in  the  year  1682.  There  is  a  notice  of 
him  in  the  "  Index  Funereus  "  of  Devaux,  a  contemporaneous 
biographical  dictionary  of  deceased  celebrities.  It  says  that 
he  was  "A  man  of  signal  integrity,  of  remarkable  piety,  and 
distinguished  in  art.  He  was  one  of  those  whose  portraits 
were  engraved  by  the  order  of  Louis  le  Grand,  and  inserted 
among  the  portraits  of  men  who  were  illustrious  in  art 
during  his  reign.  He  died  December  24th,  1683."  On  page 
50  there  is  a  notice  of  his  son,  also  a  surgeon,  who  died 
before  his  father. 

Our  Society's  portrait  is  this  original  one  of  Francois 
Herard,  painted  by  Sicre,  and  engraved  by  Louis  Cossin 
in  1682.  The  engraving  is  in  the  large  collection  of  por- 
traits at  the  Bibliotheque  Nationale,  where  it  was  discov- 
ered in  a  search  made  at  the  instance  of  M.  Le  Paulmier. 
As  another  copy  might  possibly  exist,  the  print  shops  of 
Paris  were  searched  for  one,  but  without  success.  Some 
months  afterward  I  had  another  careful  inquiry  made,  but 
equally  to   no   purpose.     There  is  a  large  collection  of  en- 


AN  OLD  PORTRAIT  OF  A  SURGEON.         365 

gravings  in  Amsterdam.  M.  MuUer  wrote  me  that  he  had 
ten  thousand  engravings  of  physicians  and  surgeons,  but 
none  of  H^rard.  An  unsuccessful  quest  was  also  made  in 
London. 

Of  this  engraving  M.  Le  Paulmier  writes  me,  that  it  is  "  a 
portrait  of  F.  Herard,  bourgeois  de  Paris,  member  of  the  Col- 
lege of  Surgery,  born  in  Paris,  and  who  died  there  December 
24,  1682.  The  'Index  Funereus'  is  in  error  in  saying  1683. 
The  engraving  of  the  Bibliotheque  Nationale  is  like  the  photo- 
graph you  sent  me,  and  underneath  it  is  a  manuscript  inscrip- 
tion mentioning  his  name  and  the  date  of  his  death,  with  his 
age.  The  portrait  you  possess  is  probably  the  original  by 
Sicre.  It  is  that  of  a  surgeon  who,  if  he  has  not  left  a  marked 
trace  in  science,  had  during  his  life  a  brilliant  clientele  and 
an  excellent  reputation." 

The  title  upon  this  engraving,  however,  being  in  manuscript, 
might  possibly  have  been  put  upon  the  portrait  of  another 
person.  I  therefore  ventured  to  write  again  to  M.  Le  Paul- 
mier upon  this  point.  His  answer  will  set  at  rest  any  doubts 
upon  this  question,  and  as  it  also  mentions  the  fact  that 
Pare  had  a  right  to  wear  a  robe  like  the  one  represented 
in  the  Society's  picture,  I  will  with  your  permission  read  a 
part  of  the  letter.  The  Society  will  notice  that  M.  Le  Paul- 
mier has  now  discovered  another  copy  of  the  engraving  of 
Herard. 

"  It  is  with  real  pleasure,"  he  says,  "  that  I  send  you  the 
information  I  have  collected  in  regard  to  your  portrait  of 
Herard. 

"  The  National  Library  possesses  two  identical  copies  of  his 
portrait  engraved  by  L.  Cossin  after  a  picture  painted  by 
F.  Sicre,  of  which  you  probably  possess  the  original. 

"  Except  that  the  head  is  turned  to  the  left,  where  we  see 
a  table  supporting  a  skull,  a  trephine,  and  an  elevator,  these 
portraits  are  the  same  as  that  in  the  photograph  you  sent  me. 


366         AN  OLD  rORTRAIT  OF  A  SURGEON. 

They  measure  twenty-four  centimeters  in  height,  and  nineteen 
in  breadth.  ^ 

"  The  impression  '  after  the  Utter '  has,  engraved  beneath  it, 
the  following  inscription  :  '  FrauQois  Herard  of  Paris,  chirur- 
gien  jure,  famous  for  trephining  and  other  operations.  F. 
Sicre  pinxit,  L.  Cossin  sculpsit.' 

"  The  Pere  Lelong,  who  copies  this  inscription  in  his 
' Bibliotheque  Historique  de  la  France,'  adds,  'Deceased  at 
Paris,  December  24,  1682.'  " 

Thinking  that  the  Society  might  like  to  see  the  original 
text  of  this  allusion  to  their  picture,  of  which  a  part  has 
been  cited  by  M.  Le  Paulmier  from  the  "  Bibliotheque  His- 
torique de  la  France,  par  Jacques  Lelong,  Paris,  1775,"  torn, 
iv..  Appendix,  p.  210,  I  have  placed  it  upon  the  table.  It 
reads  thus :  "  Frangois  Herard  de  Paris,  Chirurgien,  fameux 
pour  les  operations  du  Trepan  et  autres ;  mort  a  Paris  le  24 
Decembre,  1682.     F.  Sicre  p.  —  L.  Cossin  sc.     1682,  in  fol." 

"  The  other  impression,  that  '  hefore  the  letter^  "  writes  M. 
Le  Paulmier,  "  has  no  inscription  but  the  names  of  F.  Sicre 
and  L.  Cossin ;  but  underneath,  some  one  at  the  end  of  the 
last  century  has  written,  '  Francois  Herard,  chirurgien  de 
Paris,  mort  en  1683,  age  de  87  ans.' 

"  Let  us  now  consider  the  costume,"  continues  M.  Le  Paul- 
mier. "  There  were  formerly  two  classes  of  surgeons.  One, 
called  short-robed  {de  robe  courte'),  comprised  the  barbers, 
barber  surgeons,"  of  whom  Ambroise  Pare  had  been  one. 
"The  other,  called  long-robed  (togati)^  included  the  master 
surgeons,  or  masters  in  surgery.  These  were  members  of 
the  College  of  Saint  Come,  and  had  passed  a  more  rigorous 
examination  than  the  others."  It  was  this  long  robe  that 
Ambroise  Pare  wore  after  his  affiliation  with  Saint  C6me. 
The  significance  of  this  affiliation  will  be  better  understood 
if  we  know  what  this  society  was. 

1  The  picture  is  merely  reversed  by  printing. 


AN  OLD  PORTRAIT  OF  A  SURGEON.         367 

Saint  C6me  and  Saint  Damien  were  the  patron  saints  of 
surgeons,  and  gave  their  name  to  the  Chapelle  des  Cordeliers. 
This  church  of  Saint  Come  and  Saint  Damien,  built  in  1212, 
was  one  of  two  which  occupied  the  extremities  of  the  large 
area  enclosed  by  the  Rue  de  I'Ecole  de  Medecine,  the  Rue 
Racine,  and  the  Rue  Antoine  Dubois. 

The  surgeons  were  allowed  to  use  the  church  of  Saint  C6me 
as  a  place  of  meeting  for  a  society  for  medical  improvement 
of  the  sixteenth  century,  (^devaient  se  reunir  pour  s'instrutre 
mutuellement  dans  leur  art,)  and  also  as  a  surgical  infirmary 
for  poor  patients  gratis,  one  Monday  a  month. 

In  the  year  1515  the  church  of  Saint  Come  was  converted 
by  government  decree  into  a  surgical  college.  This  was  in 
part  demolished  in  the  year  V,  of  the  Republic,  and  was  de- 
stroyed in  1836,  except  the  Amphitheatre  of  Surgery,  which 
in  time  became  the  Dupuytren  Museum. 

Section  VIII.  of  the  Introduction  to  Malgaigne's  Complete 
Works  of  Ambroise  Pare,  Paris,  1840,  is  entitled  "  Transfor- 
mation de  la  Confr^rie  de  Saint  Come  en  College.  —  Reception 
d' Ambroise  Pare."  The  account  of  this  is  interesting  enough 
to  be  read  here  :  — 

"  Under  existing  circumstances,  the  college  had  an  immense 
interest  to  attach  to  itself  Ambroise  Pare,  who  was  in  so  great 
favor  with  the  King,  of  such  great  renown  among  the  people 
and  the  nobility.  In  spite  of  the  statutes  which  required  that 
the  candidate  should  know  Latin,  in  spite  of  the  edict  of  1544 
which  insisted  on  this  condition,  more  especially  in  spite  of 
a  difficulty  greater  than  all  the  rest,  the  necessity  of  making 
him  undergo  his  examination  in  Latin,  everything  was  con- 
ceded and  arranged  in  advance ;  they  decreed  to  him  —  per- 
haps an  unheard  of  thing  —  the  honor  of  a  free  reception ; 
and  he  asked,  in  consequence,  to  be  admitted  to  the  examina- 
tions on  the  18th  of  August,  1554 ;  he  was  named  Bachelor 
the  23d  of  the  same  month,  licensed  the  8tli  of  October,  and 


368         AN  OLD  PORTRAIT  OF  A  SURGEON. 

took  the  bonnet  de  maitre  the  1 8th  of  December,  '  in  templo 
D.  D.  Cosmae  et  Damiani  supra  fontes.'  " 

Having  landed  the  great  Ambroise  Pard  safely  among  the 
chirurgiens  de  longue  robe,  in  the  bosom  of  the  college  of  Saint 
Come,  we  can  now  understand  what  M.  Le  Paulmier  says  of 
this  robe :  — 

"  It  was  this  long  robe  that  Ambroise  Par^  wore  after 
his  affiliation  with  Saint  Come,  —  as  did  also  H^rard, — 
and,  for  that  matter,  most  of  those  who  figure  in  the  '  Index 
Funereus '  since  Francis  I.  It  was  the  official  costume, 
which  had  no  necessary  relation  with  any  other  function ; 
Frangois  Herard  himself  had  no  title  at  court.  This  will 
explain  (apropos  of  your  question  about  Juvernay,  who  him- 
self wore  one)  why  mention  is  made  of  surgeons  of  the  long 
robe, —  togatorumy 

Let  me  say  that  this  allusion  to  Juvernay  refers  to  one  M, 
Stephanus  Juvernay,  whose  name  is  in  the  "Index  Funereus," 
and  about  whom  I  inquired  of  M.  Le  Paulmier,  because  he  is 
especially  mentioned  as  "  embodying  in  himself  the  remains 
of  the  splendor  of  the  school  of  surgeons  of  the  long  robe 
(splendoris  Chirurgorum  Togatorum  scholee  reliquias  in  se 
complectens)." 

I  will  add  here  that  M.  Le  Paulmier  quite  understood  that 
the  picture  about  which  he  has  so  kindly  interested  himself 
belongs  to  the  Society. 

In  conclusion  he  says  :  — 

"  I  hope  that  I  have  replied  to  your  questions  in  a  satisfac- 
tory manner.  If  some  point  yet  remains  obscure,  I  place  my- 
self at  your  disposition.  At  all  events  it  is  perfectly  clear, 
that,  — 

"  1.  The  painted  portrait  of  which  you  have  sent  me  the 
photograph  is  that  of  F.  Herard,  painted  by  Sicre. 

"  2.  The  two  engravings  of  the  Paris  library  were  made  by 
Cossin  after  this  portrait. 


THE   STORY  OF  A  MEDICAL  PORTRAIT.  369 

"  3.  That  the  robe  with  which  this  personage  is  invested, 
as  well  as  his  collar,  is  of  the  second  half  of  the  seventeenth 
century,  and  such  as  surgeons  then  wore  (tels  que  les  por- 
taient  alors  les  chirurgiens').^^ 

M.  Le  Paulmier  has  kindly  volunteered  to  send  me  the 
engraving  of  Herard,  if  a  copy  should  ever  turn  up.  In  the 
mean  time  I  requested  Adolphe  Braun  et  Cie.  to  make  a  pho- 
tographic fac-simile  of  the  engraving  before  the  letter  which 
has  the  written  inscription  concerning  Herard,  and  also  of  the 
leaves  of  the  "  Index  Funereus  "  which  refer  to  the  Herards. 
Of  these  I  will  ask  the  acceptance  of  this  Society. 


THE   STORY   OF  A  MEDICAL  PORTRAIT  ^ 

The  first  paper  in  the  present  issue  of  the  Journal  is  a  short 
address  recently  read  by  Dr.  H.  J,  Bigelow  before  the  Boston  Soci- 
ety for  Medical  Improvement,  and  entitled  "An  Old  Portrait  of  a 
Surgeon."  Preceding  the  address  is  a  frontispiece  giving  repro- 
ductions from  a  photograph  of  an  engraving  in  the  Bibliotheque 
Nationale  at  Paris,  and  from  a  photograph  of  a  painting  owned  by 
the  Improvement  Society.  Unfortunately,  the  photograph  and  the 
reproduction  from  the  photograph  of  the  jjainting  do  not  do  it  jus- 
tice in  its  present  restored  condition;  otherwise  for  purposes  of 
comparison  the  print  suffices. 

Dr.  Bigelow's  admirable  and  critical  address  tells  the  curious 
stor}^  of  the  picture  and  of  bis  final  discovery  of  the  name  of  the 
real  subject  of  the  portrait.  For  the  full  understanding  of  tliis 
matter  by  our  readers,  and  that  they  may  share  the  interest  taken 
in  it  by  the  members  of  tlie  Society  to  which  the  portrait  belongs, 
it  remains  for  us,  availing  ourselves  of  the  facilities  offered  by  tlie 
Society  through  its  Secretary,  to  summarize  brieflj^  the  discussions 
excited  by  this  silent  old  portrait  looking  down  on  the  Society's 
meetings,  as  we  find  them  reflected  in  the  records  during  the  last 
forty  years  —  discussions  which  would  undoubtedly  have  been  lis- 

^  Boston  Medical  and  Surgical  Journal,  July  6,  1889.  —  Editorial. 

24 


370  THE   STORY   OF   A   MEDICAL   PORTRAIT. 

tened  to  with  varied  emotions  by  the  old  French  surgeon  of  the 
seventeenth  century  could  he  have  stepped  out  of  his  frame  and 
taken  his  seat  among  the  Boston  doctors  of  the  nineteenth  century. 
Their  occasional  animation  would  have  caused  a  gratified  smile ; 
but  things  were  said  in  the  heat  of  debate  which  would  have 
caused  the  shoulders  to  be  shrugged  in  a  way  visible  even  through 
the  academic  gown.  We  refer,  of  course,  strictly  to  discussions 
personal  to  the  Portrait  of  a  Surgeon,  outside  of  which  we  are  not 
authorized  on  this  occasion  to  take  the  public  into  the  confidence 
of  the  Society. 

October  9,  1848.  ''Picture  of  Ambroise  Pare.  Dr.  Bethune 
presented  to  the  Societj'  in  the  name  of  Wm.  Appleton,  Jr.,  Esq., 
this  picture,  which  there  is  good  reason  to  believe  to  be  a  portrait 
of  this  distinguished  surgeon,  painted  during  his  lifetime."  A 
vote  of  thanks  was  passed;  and  Drs.  Bethune,  0.  W.  Holmes,  and 
H.  J.  Bigelow  were  appointed  a  committee  to  provide  a  suitable 
inscription  for  the  picture.  Whether  this  committee  ever  reported 
or  not,  neither  the  records  of  the  Society  nor  the  memories  of  living 
men  declare;  but,  as  a  matter  of  fact,  the  frame  of  the  portrait 
shortly  after  bore  the  inscription  "Ambroise  Pare,"  and  as  Am- 
broise Pare  the  old  man  with  the  skull  and  trephine  continued 
traaqiiilly  to  assist  at  every  meeting  of  the  learned  Society  from 
that  time  until  the  year  1885,  when  a  stormy  period  began,  and 
the  repose  of  thirty-seven  years  was  broken. 

February  23,  1885.  "Dr.  H.  J.  Bigelow  asked  permission  of 
the  Society  to  remove  the  portrait  of  Ambroise  Pare  in  order  to 
have  it  photographed.     Permission  was  granted." 

February  23,  1886.  It  was  proposed  and  seconded  that  "the 
Secretary  inquire  when  the  portrait  purporting  to  be  of  Ambroise 
Pare,  and  now  in  the  possession  of  a  member  for  the  purpose  of 
restoration,  will  be  returned." 

October  25,  1886.  A  letter  was  received  from  Dr.  Bigelow 
returning  the  picture.  It  had  been  put  in  admirable  repair  by 
Mrs.  William  Appleton,  widow  of  the  donor,  and  a  vote  of  thanks 
to  Mrs.  Appleton  was  proposed  and  passed.  The  new  frame  still 
bore  the  inscription   "Ambroise  Pare." 

Xovember  22,  1886.  Dr.  H.  I.  Bowditch  said  that  the  portrait 
owned  by  the  Society,  purporting  to  be  Ambroise  Pare,  is  the  por- 


THE   STORY   OF  A   MEDICAL  PORTRAIT.  371 

trait  of  an  inferior  man  with  a  retreating  forehead.  In  the  opinion 
of  an  artist  whom  he  had  consulted,  the  painting  was  of  the  middle 
or  last  part  of  the  eighteenth  century.  He  referred  to  the  fact  that 
a  committee  had  been  appointed  in  1848  to  investigate  the  picture 
and  had  never  reported.  He  offered  two  resolutions :  first,  to  thank 
Dr.  Bigelow  for  his  efforts  to  have  the  picture  restored;  secondly, 
to  change  the  inscription  so  as  to  read:  — 

Presented  to  the  Medical  Improvement  Society  by 
William  Appleton,  Esq.,  in  1848. 

By  the  Kindness  of  Mrs.  Appleton 
Restored  and  Reframed  in  1886. 

The  first  motion  was  carried,  the  second  was  referred  to  a  com- 
mittee. 

December  13,  1886.  The  committee  reported  that,  in  place  of 
the  inscription  proposed  by  Dr.  Bowditch,  an  interrogation  mark 
enclosed  in  parentheses  (?)  be  added  to  the  name  of  Ambroise  Pare, 
and  that  a  reference  to  documents  on  file  respecting  the  authen- 
ticity of  the  picture  be  pasted  on  the  back  of  the  canvas.  Dr.  Bow- 
ditch  objected,  and  moved  non-acceptance  of  the  report  on  the 
ground  that  the  Societj^  would  be  acting  a  lie  if  it  continued  the 
inscription.  A  lively  debate,  in  which  various  members  took  part, 
ended  in  the  postponement  of  the  discussion  of  the  committee's 
report  to  a  subsequent   meeting. 

December  27.  Dr.  Bowditch  requested  a  further  posti^onement 
of  the  discussion. 

January  10,  1887.  Dr.  Bowditch  addressed  the  Society  on  the 
"So  called  Portrait  of  Ambroise  Pare."  He  showed  engravings 
and  photographs  of  all  the  accepted  portraits  of  Pare,  which  he 
had  been  at  great  pains  and  some  expense  to  collect,  and  pointed 
out  the  want  of  resemblance  of  the  Society's  portrait  to  any  or  all 
of  them.  He  challenged  the  authenticity  of  the  picture  as  a  por- 
trait of  Ambroise  Pare  for  the  following  reasons :  1,  the  lack  of 
resemblance  to  other  portraits  of  Pare;  2,  the  professor's  robe; 
there  was  no  evidence  that  Pare  ever  was  a  professor;  his  ignorance 
of  Latin  would  have  prevented;  3,  the  inferiority  of  the  face;  4,  it 
was  probably  a  picture  of  the  middle  or  last  part  of  the  eighteenth 
century ;  5,  the  picture  was  bought  at  auction,  coming  from  no  one 
knew  where,  and  for  nine  dollars. 


372  THE  STORY  OF  A  MEDICAL  PORTRAIT. 

At  the  close  of  his  remarks  Dr.  Bowditch  offered  two  resolutions 
in  place  of  the  committee's  report  previousl}^  under  discussion: 
first,  that  the  Society  is  grateful  to  the  donors  for  the  original 
gift;  the  picture,  however,  is  not  a  portrait  of  Ambroise  Pare, 
but  of  an  unknown  professor  of  surgery,  and  should  no  longer 
bear  the  name  of  Pare;  secondly,  that  the  President  be  requested 
to  have  the  present  inscription  removed,  and  the  inscription  pre- 
viously proposed  by  Dr.  Bowditch  put  in  its  place  on  the  frame 
of  the  picture. 

The  Society,  after  renewed  discussion,  passed  these  resolutions 
of  Dr.  Bowditch,   and  rejected  the  committee's  report. 

February  14,  1887.  Dr.  H.  W.  Williams  said  that  since  the 
last  discussion  he  had  received  from  London  a  new  book,  called 
'•'The  Healing  Art,"  in  which  it  was  stated  that  Pare  was  ap- 
pointed Professor  of  Surgery  in  the  College  of  St.  Edme.  It  was 
not  impossible  that  the  picture  might  after  all  be  Pare,  and  it 
might  be  necessary  again  to  change  the  inscription. 

Dr.  Bowditch  in  reply  said  that  it  was  singular  that  two  such 
writers  as  Malgaigne  and  Le  Paulmier  (both  biographers  of 
Pare)  do  not  mention  that  he  was  a  professor  of  surgery.  In 
fact,  they  both  state  that  he  was  always  contending  with  the 
faculty;  and  again  his  ignorance  of  Latin  was  an  insuperable 
impediment. 

October  10,  1887.  Dr.  Bowditch  reverted  to  the  statements  in 
the  book  called  "The  Healing  Art,"  cited  by  Dr.  Williams,  Feb- 
ruary 14.  He  reiterated  the  statement  that  there  w^as  no  evidence 
that  Pare  ever  was  a  professor  of  surgery ;  he  could  not  find  any 
evidence  that  any  college  of  St.  Edme  ever  existed.  The  book 
called  "The  Healing  Art"  was  unreliable;  it  was  by  an  anony- 
mous writer;  it  contained  many  errors,  some  very  absurd  ones;  he 
had  made  several  unsuccessful  attempts  to  communicate  with  the 
author  through  the  publishers,  and  he  had  been  led  to  believe  that 
the  author  could  neither  support  his  assertions  nor  find  the  candor 
to  acknowledge  his  errors.  In  closing  his  remarks  Dr.  Bowditch 
said:  "Meanwhile,  however,  our  painting,  though  it  can  never 
bear  the  honored  name  of  Pare,  has  some  considerable  merit  as  a 
work  of  art;  it  should  be  carefully  preserved;  and  I  will  respect- 
fully leave  to  the  juniors  of  the  profession  the  solution  of  the  ques- 
tion, Who  w^as  this  man  who,  notwithstanding  the  rather  inferior 


THE  STORY  OF  A   MEDICAL  PORTRAIT.  373 

characteristics  of  the  head,  was  undoubtedly  a  professor  of  surgery 
in  some  college?  " 

From  October  10,  1887,  to  April  22,  1889,  the  portrait  hung 
listlessly  in  the  Society's  place  of  meeting,  no  longer  the  centre  of 
contention,  or  even  of  interest;  still  familiarly  referred  to,  if  at  all, 
as  old  Pare,  but  proclaiming  itself  by  the  inscription  borne  since 
January,  1887,  as  the  great  unknown. 

April  22,  1889,  the  Society's  notices  offered,  among  other  an- 
nouncements, that  of  '^ Remarks  by  Dr.  H.  J.  Bigelow  on  the 
Portrait  of  a  Surgeon  " ;  after  hearing  which  remarks  the  Society 
voted,  on  motion  of  Dr.  Bowditch,  that  the  portrait  have  inscribed 
upon  its  frame  the  name  of  FrauQois  Herard! 

Dr.  Bigelow  asked  the  Society  to  authorize  him  to  express  to 
the  erudite  M.  Le  Paulmier  of  Paris  the  great  pleasure  which  his 
skilful  identification  of  their  picture  had  given  them. 

It  was  so  voted,  unanimously. 

We  have  tried  to  make  this  long  story  short,  but  do  not  doubt 
our  readers  will  find  it  worth  relating,  though  it  lead  them  for  the 
moment  away  from  the  direct  consideration  of  practical  medicine. 


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